ACTIVITIES - MHSA Concussion and SCA Packet
Acknowledgment of Sudden Cardiac Arrest (SCA) and Concussion Information
Please read each statement below carefully. You must check each box to acknowledge that you have read, understand, and agree to each statement. All acknowledgments are required.
Student Athlete Acknowledgment
Please read the following statements. You will need to acknolwledge that you have read, understand, and agree to each statement.
Sudden cardiac arrest (SCA) is a life-threatening emergency that requires immediate action, including 911 activation and use of an AED when available.
Warning signs that must be reported right away include collapse or fainting during or after exercise, chest pain with activity, unusual shortness of breath, racing or irregular heartbeat, or seizure-like activity after collapse.
Important family history, including early cardiac death or known inherited heart conditions, should be shared by parents/guardians and discussed with an appropriate medical professional.
I will report any warning sign, symptom, or episode that may be heart-related to a parent/guardian, coach, athletic trainer, or another responsible adult.
I understand that immediate action (Call 911, start CPR, use AED) can save a life.
I understand an athlete may be removed from play if warning signs or symptoms of SCA are present.
I understand that a student removed from participation because of symptoms or warning signs of SCA may not return until evaluated and provided written clearance by a licensed physician, physician assistant, or nurse practitioner.
A concussion can affect the ability to perform everyday activities such as the ability to think, balance, and perform in the classroom.
A concussion cannot be "seen." Some symptoms might be present right away. Other symptoms can show up hours or days after an injury.
I will report symptoms (my own or a teammate's) to a coach, parent, or athletic trainer immediately and will not hide or play through them.
I understand that a concussion is a serious brain injury requiring removal from play and medical evaluation and clearance before return to participation.
I (or my child) will not return to play in a game or practice if a hit to the head or body causes any concussion-related symptoms.
After a concussion, the brain needs time to heal. I understand that athletes are much more likely to have another concussion or more serious brain injury if return to play or practice occurs too soon.
You must check this box to confirm your acknowledgment of every statement above.
Electronic Signature
By signing below, I agree that my electronic signature is the legal equivalent of my handwritten signature.
Parent/Legal Guardian Acknowledgment
Please read the following statements. You will need to acknolwledge that you have read, understand, and agree to each statement.
Sudden cardiac arrest (SCA) is a life-threatening emergency that requires immediate action, including 911 activation and use of an AED when available.
Warning signs that must be reported right away include collapse or fainting during or after exercise, chest pain with activity, unusual shortness of breath, racing or irregular heartbeat, or seizure-like activity after collapse.
Important family history, including early cardiac death or known inherited heart conditions, should be shared by parents/guardians and discussed with an appropriate medical professional.
I understand that immediate action (Call 911, start CPR, use AED) can save a life.
I understand an athlete may be removed from play if warning signs or symptoms of SCA are present.
I understand that a student removed from participation because of symptoms or warning signs of SCA may not return until evaluated and provided written clearance by a licensed physician, physician assistant, or nurse practitioner.
A concussion can affect the ability to perform everyday activities such as the ability to think, balance, and perform in the classroom.
A concussion cannot be "seen." Some symptoms might be present right away. Other symptoms can show up hours or days after an injury.
I understand that a concussion is a serious brain injury requiring removal from play and medical evaluation and clearance before return to participation.
I (or my child) will not return to play in a game or practice if a hit to the head or body causes any concussion-related symptoms.
After a concussion, the brain needs time to heal. I understand that athletes are much more likely to have another concussion or more serious brain injury if return to play or practice occurs too soon.
You must check this box to confirm your acknowledgment of every statement above.
Electronic Signature
By signing below, I agree that my electronic signature is the legal equivalent of my handwritten signature.
STUDENT-ATHLETE
I acknowledge that I have received, read, and understood the Sudden Cardiac Arrest and Concussion information contained in this packet.
Electronic Signature
By signing below, I agree that my electronic signature is the legal equivalent of my handwritten signature.
PARENT / LEGAL GUARDIAN
I acknowledge that I have received, read, and understood the Sudden Cardiac Arrest and Concussion information in this packet, and have reviewed it with my student-athlete
Electronic Signature
By signing below, I agree that my electronic signature is the legal equivalent of my handwritten signature.
