Medical Release For Return To Athletic Participation Following A Concussion Or Other Injury

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MEDICAL RELEASE FOR RETURN TO ATHLETIC PARTICIPATION
FOLLOWING A CONCUSSION OR OTHER INJURY
This release is to certify that_____________________________________ has been examined
(Student-athlete’s name)
due to exhibiting the signs, symptoms, and behaviors consistent with a concussion/brain injury or other
injury. Following an examination, it is my medical opinion that he/she:
_____ Is unable to return to participation in athletics until further notice.
Return appointment scheduled on: ___________________.
(Date)
_____ May return to limited participation in athletics on ____________________________.
(Restrictions are noted below)
(Date)
_____ Following return to limited participation this student needs to return for
re-evaluation before being released for full participation in athletics.
_____ May return to full participation in athletics on _______________________________.
(Date)
Restrictions: ________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
______________________________________________________ ____________________
Health Care Provider’s Name (Type or print)
Date
______________________________________________________ ____________________
Health Care Provider’s Signature
Phone Number
Parent’s or Guardian’s Permission and Release
I hereby give my consent for my son/daughter to return to participation following his/her concussion or
other injury as per the instructions detailed above.
______________________________________________________ __________________
Parent’s or Guardian’s Signature
Date
__________________________________ __________________________________
Parent’s or Guardian’s Home Phone #
Parent’s or Guardian’s Work Phone #
SEE PAGE 2 OF THIS FORM FOR
RETURN TO PARTICIPATION PROTOCOL FOLLOWING A CONCUSSION
(GUIDELINES FOR LICENSED HEALTH CARE PROVIDERS)
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