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Rev. April 2012 CONCUSSION ACKNOWLEDGEMENT FORM Name of Student Definition of Concussion means a complex pathophysiological process affecting the brain caused by a traumatic physical force or impact

How to fill out concussion acknowledgement form

How to fill out a concussion acknowledgement form:

1. Begin by reading the concussion acknowledgement form thoroughly. Make sure you understand all the information and requirements mentioned in the form.
2. Provide your personal information accurately. This may include your full name, contact details, date of birth, and any other relevant information requested.
3. Pay attention to the sections that require you to acknowledge your understanding of concussion-related risks and symptoms. Check the boxes or fill in the blanks as required.
4. If the form includes any questions or statements regarding previous concussions or head injuries, answer truthfully. This information is crucial for assessing your risk factors.
5. Sign and date the form at the designated spaces to verify that you have read and understood the contents. Make sure to use your legal signature.
6. If the form requires additional signatures, ask the appropriate individuals to review and sign as necessary. This could include a parent or guardian, coach, or healthcare provider.
7. Keep a copy of the completed form for your records. It's always a good idea to have documentation of your acknowledgement.

Who needs a concussion acknowledgement form:

1. Athletes: Concussion acknowledgement forms are typically required for individuals participating in organized sports, especially contact sports. This helps ensure that athletes are aware of the risks associated with concussions and can make informed decisions about their participation.
2. Students: Many schools and educational institutions require concussion acknowledgement forms for students involved in physical education classes, sports teams, or other extracurricular activities.
3. Employees: Some workplaces, particularly those in physically demanding industries or professions, may require employees to complete concussion acknowledgement forms to ensure their safety and awareness of potential workplace hazards.
4. Volunteers: Organizations that involve volunteers in physically active roles or events may request concussion acknowledgement forms. This helps protect both the volunteers and the organization from liability in case of injuries.
5. Parents or guardians: In cases where the individual filling out the concussion acknowledgement form is a minor, a parent or guardian may need to sign the form on their behalf, acknowledging their understanding of the risks involved.

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