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Athletics Handbook » Concussion or Head Injury - Return to Play Form

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.
 
 
 Date: ________________________________         ____________________________________________
 (signature of parent)