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Amateur Athletic Union

Mild Traumatic Brain Injury (MTBI) / Concussion

Annual Statement and Acknowledgement Form:

The athlete acknowledgesthat I have to be an active participant in my own health and have the direct responsibility for reporting all of my injuries and illnesses to the organizations staff (e.g., coaches, team physicians, and athletic training staff). I further recognize that my physical condition is dependent upon providing an accurate medical history and a full disclosure of any symptoms, complaints, prior injuries and/or disabilities experienced before, during or after athletic activities.

By signing below, I acknowledge:

My organization has provided me with specific educational materials including the CDC Concussion fact sheet (http://www.cdc.gov/concussion/HeadsUp/youth.html) on what a Concussion is and has given me an opportunity to ask questions. FACT sheets are different for Parents, Coaches, and Players.

I ACKNOWLEDGE THAT I HAVE READ THE FACT SHEET on the CDC website for Parents and Players.

I have fully disclosed to the staff any prior medical conditions and will also disclose any future conditions.

There is a possibility that participation in my sport may result in a head injury and/or concussion.

In rare cases, these concussions can cause permanent brain damage, and even death.

A concussion is a brain injury, which I am responsible for reporting to the team physician, athletic trainer, coach, parent volunteer, or official.

A concussion can affect my ability to perform everyday activities, and affect my reaction time, balance, sleep, and classroom performance.

Some of the symptoms of concussion may be noticed right away while other symptoms can show up hours or days after the injury.

If I suspect a teammate has a concussion, I am responsible for reporting the injury to the staff.

I will not return to play in a game or practice if I have received a blow to the head or body that results in concussion related symptoms.

I will not return to play in a game or practice until my symptoms have resolved AND I have written clearance to do so by a qualified health care professional.

Following concussion the brain needs time to heal and you are much more likely to have a repeat concussion or further damage if you return to play before your symptoms resolve.

Based on the incidence of concussion as published by the CDC the following sports have been identified as high risk for concussion; baseball, basketball, diving, football, pole vaulting, soccer, softball, spirit line, wrestling, lacrosse, mixed martial arts, and rugby. All forms provided by CDC.

I represent and certify that I and my parent/guardian have read the entirety of this document and fully understand the contents, consequences and implications of signing this document and that I agree to be bound by this document.

Concussion Information Sheet

A concussion is a brain injury and all brain injuries are serious. They are caused by a bump, blow, or jolt to the head, or by a blow to another part of the body with the force transmitted to the head. They can range from mild to severe and can disrupt the way the brain normally works. Even though most concussions are mild, all concussions are potentially serious and may result in complications including prolonged brain damage and death if not recognized and managed properly. In other words, even a “ding” or a bump on the head can be serious. You can’t see a concussion and mostsports concussions occur without loss of consciousness. Signs and symptoms of concussion may show up right after the injury or can take hours or days to fully appear. If your child reports any symptoms of concussion, or if you notice the symptoms or signs of concussion yourself, seek medical attention right away.

Symptoms may include one or more of the following:

Signs observed by teammates, parents, and coaches include:

Appears dazed

Vacant facial expression

Confused about assignment

Forgets plays

Is unsure of game, score, or opponent

Moves clumsily or displays coordination issues

Answers questions slowly

Slurred speech

Shows behavior or personality changes

Can’t recall events prior to hit

Can’t recall events after hit

Seizures or convulsions

Any change in typical behavior or personality

Loss of consciousness

What can happen if my child keeps on playing with a concussion or returns to soon?

Athletes with the signs and symptoms of concussion should be removed from play immediately. Continuing to play with the signs and symptoms of a concussion leaves the young athlete especially vulnerable to greater injury. There is an increased risk of significant damage from a concussion for a period of time after that concussion occurs, particularly if the athlete suffers another concussion before completely recovering from the first one. This can lead to prolonged recovery, or even to severe brain swelling (second impact syndrome) with devastating and even fatal consequences. It is well known that adolescent or teenage athlete will often under report symptoms of injuries. And concussions are no different. As a result, education of administrators, coaches, parents and students is the key for student-athlete’s safety.

If you think your child has suffered a concussion

Any athlete even suspected of suffering a concussion should be removed from the game or practice immediately. No athlete may return to activity after an apparent head injury or concussion, regardless of how mild it seems or how quickly symptoms clear, without medical clearance. Close observation of the athlete should continue for several hours. The new CIF Bylaw 313 now requires implementation of long and well-established return to play concussion guidelines that have been recommended for several years:

“A student-athlete who is suspected of sustaining a concussion or head injury in a practice or game shall be removed from competition at that time and for the remainder of the day.”

And

“A student-athlete who has been removed may not return to play until the athlete is evaluated by a licensed heath care provider trained in the evaluation and management of concussion and received written clearance to return to play from that health care provider”.

You should also inform your child’s coach if you think that your child may have a concussion. Remember it’s better to miss one game than miss the whole season. And when in doubt, the athlete sits out.

For current and up-to-date information on concussions you can go to: http://www.cdc.gov/ConcussionInYouthSports/

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I declare under penalty of perjury (U.S. Code Title 28, Part V, Chapter 115, Section 1746) that all the information is true and correct to the best of my knowledge. I understand that anyone who knowingly gives false or misleading information (U.S. Code Title 18, Part 1, Chapter 47, Section 1028) commits a crime punishable under Federal law by fine, imprisonment or both.
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I declare under penalty of perjury (U.S. Code Title 28, Part V, Chapter 115, Section 1746) that all the information is true and correct to the best of my knowledge. I understand that anyone who knowingly gives false or misleading information (U.S. Code Title 18, Part 1, Chapter 47, Section 1028) commits a crime punishable under Federal law by fine, imprisonment or both.

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Please have the following item when registering:
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2. Digital photo required from your computer.
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I declare under penalty of perjury (U.S. Code Title 28, Part V, Chapter 115, Section 1746) that all the information is true and correct to the best of my knowledge. I understand that anyone who knowingly gives false or misleading information (U.S. Code Title 18, Part 1, Chapter 47, Section 1028) commits a crime punishable under Federal law by fine, imprisonment or both.
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