Head Injury Waiver Form

*NO DRUGS OF ANY KIND (TYLENOL, ADVIL, ETC.) FOR 24 HOURS*

A concussion is the immediate and temporary impairment of the brain to function normally following a direct hit to the head. Signs and symptoms usually occur soon after the injury but, in some cases, may be delayed.

Symptoms include the following:

  • “Pressure in the 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
  • Amnesia
  • Don’t feel right”
  • Fatigue or low energy
  • Sadness
  • Nervousness or anxiety
  • Irritability
  • More emotional
  • Confusion
  • Concentration or memory problems
  • Repeating the same question/comment
  • Headaches

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 incoordination
  • 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
  • Loses consciousness

If any of the following symptoms intensify or begin after your athlete is released to you, call 911 immediately:

  • Bleeding from the nose and ears
  • Paralysis or marked weakness of limbs and facial muscles
  • Drainage of fluids from nose or ears
  • Loss of consciousness
  • Nausea and vomiting

What can happen if you keep on playing with a concussion or return 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 athletes will often under-report symptoms of injuries. And concussions are no different. As a result, the education of administrators, coaches, parents, and students is the key to student-athlete safety.

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Signature of Student-Athlete
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