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Concussion Release Form

KSHSAA RECOMMENDED CONCUSSION & HEAD INJURY INFORMATION RELEASE FORM

This form must be signed by all student athletes and parent/guardians before the student participates in any athletic or spirit practice or contest each school year.

A sports related concussion is a traumatic brain injury, caused by a direct blow to the head, neck, or body resulting in an impulsive force being transmitted to the brain that occurs in sports and exercise related activity. Symptoms and signs may present immediately or evolve over minutes to days. Sports related concussions commonly resolve within days but may be prolonged. All concussions are potentially serious and may result in complications including prolonged brain damage and death if not recognized and managed properly. If a student 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:

● Headaches/“Pressure in head” ● Nausea or vomiting ● Neck pain ● Balance problems or dizziness ● Blurred, double, or fuzzy vision ● Sensitivity to light or noise ● Feeling sluggish or slowed down ● Feeling foggy or groggy ● Drowsiness ● Change in sleep patterns ● “Don’t feel right” ● Unexplained nervousness, anxiety, irritability, sadness ● Confusion ● Concentration or memory problems (forgetting sport assignments) ● Repeating the same question/comment

Signs observed by teammates, parents, and coaches include:

● Actual or suspected loss of consciousness ● Seizure ● Tonic posturing ● Ataxia (clumsy voluntary movements) ● Poor balance ● Appears dazed ● Vacant facial expression ● Confusion ● Forgets sport plays/assignments ● Is unsure of game, score, or opponent ● Answers questions slowly ● Slurred speech ● Shows behavior or personality changes ● Can’t recall events prior to injury ● Can’t recall events after injury

RED FLAGS: Call an Ambulance

● Neck pain or tenderness ● Seizure, ‘fits’, or convulsion ● Loss of vision or double vision ● Loss of consciousness ● Increased confusion or deteriorating conscious state (becoming less responsive, drowsy) ● Weakness or numbness/tingling in more than one arm or leg ● Repeated vomiting ● Severe or increasing headache ● Increasingly restless, agitated or combative ● Visible deformity of the skull

What can happen if my child keeps on playing with a concussion or returns too 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 (second impact syndrome). This can lead to prolonged recovery, or even to severe brain swelling with devastating and even fatal consequences. It is well known that adolescent or teenage athletes 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 and an urgent referral to a health care provider should be arranged (if not already onsite). No athlete may return to activity after sustaining a concussion, regardless of how mild it seems or how quickly symptoms clear, without written medical clearance from a Medical Doctor (MD) or Doctor of Osteopathic Medicine (DO). Close observation of the athlete should continue for several hours. You should also inform your child’s coach if you think that your child may have a concussion. Remember it is better to miss one game than miss the whole season. When in doubt, the athlete sits out!

Cognitive Rest & Return to Learn

The first step in concussion recovery is relative rest for the first 24-48 hours. During this time students may participate in activities of daily living and may perform light physical activity, such as walking, provided symptoms are not more than mildly exacerbated for only a brief (less than an hour) period of time. Reduced screen time is also recommended during the first day or two after injury. Students should be encouraged to return back to a normal routine as quickly as possible, tolerating a mild exacerbation of symptoms with mental activity. Students may need adjustments to their academic workload for a short period of time while recovering from a concussion. Trying to meet all academic requirements too soon after sustaining a concussion may more than mildly exacerbate symptoms and delay recovery. Any academic modifications should be coordinated jointly between the student’s medical providers and school personnel. To minimize academic and social disruptions, in most cases it is recommended students not be completely isolated, even for a short period of time. Rather students should continue to participate in activities of daily living that do not more than mildly exacerbate concussion symptoms.

Return to Practice and Competition

The Kansas School Sports Head Injury Prevention Act provides that if an athlete suffers, or is suspected of having suffered, a concussion or head injury during a competition or practice, the athlete must be immediately removed from the competition or practice and cannot return to practice or competition until a Health Care Professional has evaluated the athlete and provided a written authorization to return to practice and competition. The KSHSAA recommends that an athlete not return to practice or competition the same day the athlete suffers or is suspected of suffering a concussion. The KSHSAA also recommends that an athlete’s return to practice and competition should follow a graduated protocol under the supervision of the health care provider (MD or DO).

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

For concussion information and educational resources collected by the KSHSAA, go to:  http://www.kshsaa.org/Public/General/ConcussionGuidelines.cfm

___________________________  ______________________   _______ Student-athlete Name Printed          Student-Athlete Signature        Date ___________________________ _____________________________  ____ Parent or Legal Guardian Printed   Parent or Legal Guardian Signature   Date

The parties to this document agree that an electronic signature is intended to make this writing effective and binding and to have the same force and effect as the use of a manual signature.

  • Health & Safety