Concussion Awareness Form (Youth Sports)
Participant Information
Athlete Name
Sport
Season/Year
Concussion Education
I understand that:
A concussion is a brain injury that can affect physical, mental, and emotional health.
Concussions can happen during practice, games, or other recreational activities.
Symptoms of concussion may occur immediately or hours/days after the injury.
Continuing to play after a concussion can increase the risk of more serious injury.
It is important to report concussion symptoms to coaches and parents/guardians.
Athletes should only return to play with medical clearance from a healthcare professional.
Symptoms of Concussion
Headache or "pressure" in head
Nausea or vomiting
Balance problems or dizziness
Double or blurry vision
Confusion or memory problems
Sensitivity to light or noise
Feeling sluggish, hazy, foggy, or groggy
Concentration or attention problems
Signatures
I have read and understand this concussion awareness information.
As a parent/guardian, I have also reviewed this information.
Athlete Signature
Date
Parent/Guardian Signature
Date