CONSENT AND RELEASE FROM LIABILITY CERTIFICATE FOR CONCUSSION
What is a concussion? Concussion is a brain injury. Concussions, as well as all other head injuries, are serious. They can be caused by a bump, a twist of the
head, sudden deceleration or acceleration, a blow or jolt to the head, or by a blow to another part of the body with force transmitted to
the head. You can’t see a concussion, and more than 90% of all 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. All concussions are potentially
serious and, if not managed properly, may result in complications including brain damage and, in rare cases, even death. Even a “ding”
or a bump on the head can be serious. If your child reports any symptoms of concussion, or if you notice the symptoms or signs of
concussion yourself, your child should be immediately removed from play, evaluated by a medical professional and cleared by a
medical doctor. What are the signs and symptoms of concussion?
Concussion symptoms may appear immediately after the injury or can take several days to appear. Studies have shown that it takes on
average 10-14 days or longer for symptoms to resolve and, in rare cases or if the athlete has sustained multiple concussions, the
symptoms can be prolonged. Signs and symptoms of concussion can include: (not all-inclusive)
• Vacant stare or seeing stars • Lack of awareness of surroundings • Emotions out of proportion to circumstances (inappropriate crying
or anger) •
Headache or persistent headache, nausea, vomiting • Altered vision • Sensitivity to light or noise • Delayed verbal and motor responses
• Disorientation, slurred or incoherent speech • Dizziness, including light-headedness, vertigo(spinning) or loss of equilibrium (being off
balance or swimming sensation) • Decreased coordination, reaction time • Confusion and inability to focus attention • Memory loss •
Sudden change in academic performance or drop in grades • Irritability, depression, anxiety, sleep disturbances, easy fatigability • In
rare cases, loss of consciousness
What can happen if my child keeps on swimming with a concussion or returns too soon?
Athletes with signs and symptoms of concussion should be removed from activity (play or practice) immediately. Continuing to play with
the signs and symptoms of a concussion leaves the young athlete especially vulnerable to sustaining another concussion. Athletes who
sustain a second concussion before the symptoms of the first concussion have resolved and the brain has had a chance to heal are at
risk for prolonged concussion symptoms, permanent disability and even death (called “Second Impact Syndrome” where the brain
swells uncontrollably). There is also evidence that multiple concussions can lead to long-term symptoms, including early dementia.
What do I do if I suspect my child has suffered a concussion?
Any athlete suspected of suffering a concussion should be removed from the activity 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 written medical
clearance from an appropriate health-care professional (AHCP). In Florida, an appropriate health-care professional (AHCP) is defined
as either a licensed physician (MD, as per Chapter 458, Florida Statutes), a licensed osteopathic physician (DO, as per Chapter 459,
Florida Statutes), or a licensed physicians assistant under the direct supervision of a MD/DO (as per Chapters 458 and 459, Florida
Statutes). Close observation of the athlete should continue for several hours. You should also seek medical care and inform your child’s
coach if you think that your child may have a concussion. Remember, it’s better to miss one game than to have your life changed
forever. When in doubt, sit them out.
When can my child return to play or practice?
Following physician evaluation, the return to activity process requires the athlete to be completely symptom free, after which time
they would complete a step-wise protocol under the supervision of a licensed athletic trainer, coach or medical professional and then,
receive written medical clearance of an AHCP. For current up-to-date information on concussions visit
http://www.cdc.gov/concussioninyouthsports/ or http://www.cdc.gov/concussioninyouthsports/
Statement of Parent Responsibility:
I have read and understand the above information on concussion. I realize if my child/children display any of these symptoms
that I should consider seeking medical attention for my child/children. Furthermore, I have been advised of the dangers of
participation for that of my child/children.
YES, I AGREE.
Enter your initials to indicate acceptance: