Concussion Notification ~ Sample

Fairbanks Youth Soccer Association

Possible Concussion Notification

Date of Injury: _____________

Team Division: _____________________ Team Name: __________________________

Player Name:_____________________________________________________________

Coach/Volunteer Name: ____________________________ Phone#_________________

Injury Occurred During: Practice ~ Game ~ Scrimmage ~ Tournament ~ Other____________

How Injury Occurred: ______________________________________________________

_________________________________________________________________________

Parents:

The above player may have received a possible concussion during the event listed above. Fairbanks Youth Soccer Association wants to make sure the player and the parent / legal guardian are aware of the possibility and the signs and symptoms that may arise which may require further evaluation and / or treatment.

It is common for a concussed child to have one or many concussion symptoms. There are four types of symptoms: physical, cognitive, sleep and emotional. Please refer to the "Head Up Concession Sheet" you have been given for a detailed list of symptoms. If you notice signs of the symptoms listed or there any other symptoms you notice about the behavior or conduct of your son or daughter, you should consider seeking immediate medical attention.

Please take the necessary precautions and seek a professional medical opinion before allowing your daughter or son to participate further. Until a professional medical opinion is provided, please consider the following guidelines:

  1. Players shall not re-enter game, practice, or partake in any soccer related activities for at least 24 hours. Even if there are no signs or symptoms after 15-20 min, activity should not be taken by the player.
  2. Refrain from taking any medications unless proscribed by medical doctor for the current injury

Coach and Parents:

Please be advised that a player who suffers a concussion may not return to play until there is a signed release provided by a medical doctor; There Are No Exceptions. The signed medical release must be presented to the FYSA Office prior to re-entering team activities. FYSA will then notify the team coach or team volunteer, and referee representative regarding the release of the player to participate in FYSA activities.

Player Signature: _____________________________________________________________Date: ___________

Parent/ Guardian Signature:_____________________________________________________Date: ___________

Team Coach / Volunteer Signature:_______________________________________________Date: ___________

Parent Phone Verification: Yes or No Phone #: _________________ Time: ______________Date: ___________

By signing the Possible Concussion Notification form, I confirm that I have been provided with, and acknowledge that, I have read the information contained in the form.

FYSA Release of Player: Yes or No Parent Notified of Release: Yes or No Coach Notified of Release: Yes or No

Release Granted: ______________________________________________________________ Date: __________

FYSA Executive Director

Release Denied: _______________________________________________________________ Date: __________

FYSA Executive Director

Fairbanks Youth Soccer Association ~ Phone ~ (907) 456-3976 ~ Email ~ fysa@mosquitonet.com