Concussion or Head Injury - Return to Play Form
Student Name: _______________________________________ DOB: ___________ Grade: ________
Date of Injury: _______________________________________
Health Care Provider Medical Clearance and Written Authorization to Return to Play
I, ___________________________________________, with Health Care License # ______________
(print health care provider name)
of _________________________________________________________________________
(print business name and address)
by signing this Concussion or Head Injury Return to Play Form certify the following:
- I am licensed, certified, or otherwise statutorily authorized by the State of New Hampshire to
- provide medical treatment and am trained in the evaluation and management of concussions.
- I examined the above-named student on the date listed below.
- I explained to the student and the student's parent/guardian the nature and risks of concussions or
- head injuries including the risks of continuing to play and practice after sustaining a concussion
- or head injury.
- I have medically cleared the above-named student to return to play and practice without any
- restrictions.
- The above-named student has my written authorization to return to play and practice.
Date: __________________________ _______________________________________
(signature of health care provider)
Parent/Guardian Written Permission to Return to Play
I, __________________________________________ am the parent/guardian of the above-named
(print name of parent/guardian)
student who was removed from play at a practice or game because of a suspected concussion or headinjury. By signing this Concussion or Head Injury Return to Play Form, I certify the following:
- My child was evaluated by our health care provider who is listed above and has received written
- medical clearance to return to play and practice.
- Our health care provider has explained to us the nature and risk of concussions and head injuries
- including the risks to my child of continuing to play and practice after sustaining a concussion or
- head injury.
- I understand, acknowledge, and accept the risks of my child returning to play and practice.
- I understand and acknowledge that my child cannot return to play and practice without my
- written permission.
- I give my written consent and permission for my child to return to play and practice.
(signature of parent)