Mus Pre-Participation Medical History Form - 2016-2017 Page 4
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8Student-athlete & Parent/Legal Guardian Concussion Statement
Must be signed and returned to school or community youth athletic activity prior to participation in
practice or play.
Student-Athlete Name: _________________________________________________________
Parent/Legal Guardian Name(s): _________________________________________________
A concussion is a brain injury which should be reported to my parents, my coach(es) or a medical
1)
professional if one is available. ___________
___________
Student Initials
Parent Initials
2) A concussion cannot be “seen.” Some symptoms might be present right away. Other symptoms can show
up hours or days after an injury. ___________
___________
Student Initials
Parent Initials
3) I will tell my parents, my coach and/or a medical professional about my injuries and illnesses.
___________
Student Initials
4) I will not return to play in a game or practice if a hit to my head or body causes any concussion-related
symptoms.
__________
Student Initials
5) I will/my child will need written permission from a health care provider to return to play or practice after a
concussion.
__________
____________
Student Initials
Parents Initials
6) Most concussions take days or weeks to get better. A more serious concussion can last for months or
longer.
___________
____________
Student Initials
Student Initials
7) After a bump, blow or jolt to the head or body an athlete should receive immediate medical attention if
there are any danger signs such as loss of consciousness, repeated vomiting or a headache that gets worse.
___________
____________
Student Initials
Parent Initials
8) After a concussion, the brain needs time to heal. I understand that I am/my child is much more likely to
have another concussion or more serious brain injury if return to play or practice occurs before the
concussion symptoms go away.
___________
_____________
Student Initials
Parent Initials
9) Sometimes repeat concussion can cause serious and long-lasting problems and even death.
____________
____________
Student Initials
Parent Initials
10) I have read the concussion symptoms on the Concussion Information Sheet.
____________
____________
Student Initials
Parent Initials
____________________________
____________________
Student Signature
Date
_____________________________
_____________________
Parent Signature
Date
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