Athletics Pre-Participation Head Injury/ Concussion Reporting Form

Student First Namerequired

Student Last Namerequired

Student Addressrequired

Cityrequired

Staterequired

Zip Coderequired

Student Date of Birthrequired

Month

Student Date of Birthrequired

Date

Student Date of Birthrequired

Year

Student Year of Graduationrequired

Student Sport & Levelrequired

Parent First Namerequired

Parent Last Namerequired

Parent Cell Phonerequired

Parent Email Addressrequired

How many traumatic head injuries has the student experienced?required

Date of Head Injuryrequired

Month, Date and Year, if possible

Did the student receive medical treatment for the head injury?*

Yes No

Date(s) of treatment for head injury

Month, Date and Year, if possible

Explain how the injury occurred:required

Was the student diagnosed with a concussion?*

Yes No

If not, what was the diagnosis:

Describe the symptoms and their duration:required

What was the treatment plan:required

Date of Head Injuryrequired

Month, Date and Year, if possible

Did the student receive medical treatment for the head injury?*

Yes No

Date(s) of treatment for head injury

Month, Date and Year, if possible

Explain how the injury occurred:required

Was the student diagnosed with a concussion?*

Yes No

If not, what was the diagnosis:

Describe the symptoms and their duration:required

What was the treatment plan:required

Date of Head Injuryrequired

Month, Date and Year, if possible

Did the student receive medical treatment for the head injury?*

Yes No

Date(s) of treatment for head injury

Month, Date and Year, if possible

Explain how the injury occurred:required

Was the student diagnosed with a concussion?*

Yes No

If not, what was the diagnosis:

Describe the symptoms and their duration:required

What was the treatment plan:required

Date of Head Injuryrequired

Month, Date and Year, if possible

Did the student receive medical treatment for the head injury?*

Yes No

Date(s) of treatment for head injury

Month, Date and Year, if possible

Explain how the injury occurred:required

Was the student diagnosed with a concussion?*

Yes No

If not, what was the diagnosis:

Describe the symptoms and their duration:required

What was the treatment plan:required

Date of Head Injuryrequired

Month, Date and Year, if possible

Did the student receive medical treatment for the head injury?*

Yes No

Date(s) of treatment for head injury

Month, Date and Year, if possible

Explain how the injury occurred:required

Was the student diagnosed with a concussion?*

Yes No

If not, what was the diagnosis:

Describe the symptoms and their duration:required

What was the treatment plan:required

Heads Up! Concussion in Youth Sports Course

All athletes and parents of athletes are required to complete the Heads Up! Concussion in Youth Sports course every year. You can find the course online here.

Electronic Signature*

By checking this box I affirm that both myself and my daughter(s) have completed the Heads Up! Concussion in Youth Sports course for the 2022-23 school year. This checkbox serves as an electronic signature.

Electronic Signature