Concussion Form

Any 4591 Sports Development  athlete under the age of 18 years suspected of having sustained a concussion or traumatic head injury must be removed immediately from participation in 4591 Sports Development sporting event (e.g. sanctioned training, practice, camps, competitions or tryouts), by the Technical Delegate or 4591 Sports Development member coach overseeing such sporting event. The minor athlete will be prohibited from further participation until evaluated and cleared in writing to resume participation in 4591 Sports Development sporting events by a qualified health care provider trained in the evaluation and management of concussive head injuries. The health care professional must certify to 4591 Sports Development in the clearance letter that he/she has successfully completed a continuing education course in the evaluation and management of concussive head injuries within three years of the day on which the written statement is made. Upon removal of a minor athlete from participation for a suspected concussion or traumatic head injury, the 4591 Sports Development  or member coach making the removal must inform 4591 Sports Development Competition Services. Athletes who have subsequently been medically cleared to resume participation must provide such medical clearance (as described above) to 4591 Sports Development Competition Service in order to be permitted to participate in 4591 Sports Development sporting events. About Concussion A concussion is a type of traumatic brain injury (TBI) caused by a bump, blow, or jolt to the head. Concussions can also occur from a fall or a blow to the body that causes the head and brain to move quickly back and forth. Doctors may describe a concussion as a “mild” brain injury because concussions are usually not life-threatening. Even so, their effects can be serious. Risk of Continued Participation A repeat concussion that occurs before the brain recovers from the first—usually within a short period of time (hours, days, or weeks)—can slow recovery or increase the likelihood of having long-term problems. In rare cases, repeat concussions can result in edema (brain swelling), permanent brain damage, and even death. The 4591 Sports Development recommends that Members review the Center for Disease Control’s resources on concussion awareness at the following link: http://www.cdc.gov/concussion/HeadsUp/online_training.html  

* I HAVE CAREFULLY READ THE FOREGOING AND UNDERSTAND IT TO BE A LEGALLY BINDING RELEASE AND INDEMNITY AGREEMENT By his/her signature below, MEMBER CERTIFIES THAT HE/SHE HAS READ AND UNDERSTOOD THIS AGREEMENT, and agrees in full with its terms, intend that it be binding on Member, his/her heirs, executors, administrators and assigns, and that it remain in full force and effect for as long as Member participates in 4591 Sports Development  training, competition and related programs and activities without independent medical and accident insurance.

MEMBER Signature: ______________________________________________________________ Date of Birth: ________________________________

Printed name:______________________________ ______________

Member No.:___________Date Signed: ________________________________

SIGNATURE OF PARENT OR GUARDIAN REQUIRED BELOW FOR MINOR*** MEMBERS As the parent or guardian of the minor Member named above, I hereby make and enter into each and every agreement, representation, waiver and release described above on behalf of myself, the Member, and any other parent or guardian of the Member, intending that they be binding on me, the Member, and our respective heirs, executors, administrators and assigns. I intend to give up my right, the Member’s right, and the right of any other parent or guardian to maintain any claim or suit against 4591 Sports Development arising out of the Member's participation in any Activities involving 4591 Sports Development  in any way.

Parent or guardian’s signature____________________________________

Printed name________________________________________________________________ Date_______________________________________________

THIS DOCUMENT DEPRIVES YOU OF ANY LEGAL RIGHT TO SUE 4591 Sports Development, EVEN FOR ITS OWN NEGLIGENCE. DO NOT SIGN AND INITIAL IT UNLESS YOU HAVE READ IT IN ITS ENTIRETY. SEEK THE ADVICE OF LEGAL COUNSEL IF YOU ARE UNSURE OF ITS EFFECT

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Rice Lake, WI. 54868