2016 - 2017CONCUSSION and SUDDEN CARDIAC ARREST

ACKNOWLEDGEMENT AND SIGNATURE FORM FOR PARENTS AND STUDENT ATHLETES

Student Athlete’s Name (Please Print):

_________________________________________________________

Sport Participating In (Current and Potential):

____________________________________________________

School:

_______________________________________________

Grade:

__________________

IC 20-34-7 and IC 20-34-8 require schools to distribute information sheets to inform and educate

student athletes and their parents on the nature and risk of concussion, head injury and sudden cardiac

arrest to student athletes, including the risks of continuing to play after concussion or head injury.

These laws require that each year, before beginning practice for an interscholastic sport, a student

athlete and the student athlete’s parents must be given an information sheet, and both must sign and

return a form acknowledging receipt of the information to the student athlete’s coach.

IC 20-34-7 states that an interscholastic student athlete, in grades 5-12, who is suspected of sustaining a

concussion or head injury in a practice or game, shall be removed from play at the time of injury and

may not return to play until the student athlete has received a written clearance from a licensed health

care provider trained in the evaluation and management of concussions and head injuries, and at least

twenty-four hours have passed since the injury occurred.

IC 20-34-8 states that a student athlete who is suspected of experiencing symptoms of sudden cardiac

arrest shall be removed from play and may not return to play until the coach has received verbal

permission from a parent or legal guardian for the student athlete to return to play. Within twenty-four

hours, this verbal permission must be replaced by a written statement from the parent or guardian.

Parent/Guardian - please read the attached fact sheets regarding concussion and sudden cardiac arrest

and ensure that your student athlete has also received and read these fact sheets. After reading these

fact sheets, please ensure that you and your student athlete sign this form, and have your student

athlete return this form to his/her coach.

As a student athlete, I have received and read both of the fact sheets regarding concussion and sudden

cardiac arrest. I understand the nature and risk of concussion and head injury to student athletes,

including the risks of continuing to play after concussion or head injury, and the symptoms of sudden

cardiac arrest.

(Signature of Student Athlete) (Date)

I, as the parent or legal guardian of the above named student, have received and read both of the fact

sheets regarding concussion and sudden cardiac arrest. I understand the nature and risk of concussion

and head injury to student athletes, including the risks of continuing to play after concussion or head

injury, and the symptoms of sudden cardiac arrest.

(Signature of Parent or Guardian) (Date)

Updated April 2016

TURN IN THIS PAGE SIGNED!

PARENTS: PLEASE KEEP THE “FACT SHEETS” FOR YOUR FUTURE REFERENCE!

H£RUSU?. %LI1H I

C0 N CUSSI ui SpORTS

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A FACT SHEET FOR F[iiTII

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tr9ing tc vtcugh it out’ ftn mk snptrn wotseT[[ rur coi:h. prn:t ind ath[ti: trainr f thinkyo U Ot on cf cur tamints may hae a cncu sion.Dc!nt [t arr’cn prsur into continuinq t prathcor pLa’ with a cncuson.

GETCHECKED QUT On[ a ha[th cr prcFsiona[c, t2U. if ou hi i oncusin nd when it O torturin to p[c Sports have injuri tirrnouts and p[r5ubstitutions so that cu can gt chckd cut nd theteani can pei1Dm t rts best. Ih soonr ‘:u qt chckd0 Ut, the snr U m b abbe t afb’ icturm tc pI..

TAJE CARE OF YOUR BRMN A conusin can affctyour abiLity ta do shocLwk and othr activities. McstithLekes with a concusior t better nd retuTn to5porb but it s inptant to nest d qi iou braintime th heL A rpt conasicn that occurs whiLe ‘curbrain is stiLt hLinq can :aue [onq-trri proliLenis thatm chmqe [if fier.

How cati I he(p ptever’it a conuission?Er 5pt is diffeent but thee ar ste5 ou cn tkto protect cursf.

* Fo[[ow ur coach’s Tube5 i sifet’ rd th fu[e5 ofth sporL

. PfactiE good sporbmanshp at at[ tin.

If yciu think rou have a co:ncuscion:Donrt hfde it Report it. Take time to eoer

Pfts better ft miss one qme then the whole season.FOT moTe infonnticn. sit wwwc&ov/Corcuscion.

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H£RSUP__-1— AILINNCo NCUSSIui

A FACT SHEET FOR PfiEHTS

Wha.t is a torcussor?A :cncuson is a tp of triurnatic ran :nusicnar caui y a um; or bw ta th hd. a ding’•;ffln; :cur ru cr what sni to li a nitd bumpcr b[ow to th h’ad ca[ b ius.

You cait a con:us[o. Signs an sniptonis of cncusioncan how p riht aftr injury or m no apam or b•iti:d urihi d’s r aftm inj’jry. Ifyour chitdrport an synipom5 cf couioi, ci f cu noiCe th5Sfl:pb3m5 J[Lt5iLf, 5k ricai atteriticn right

What are the signs and syniptorns of aconcussion?If cur chiL a5 a bump r b[c’ ta th hddurinq a ;am r prcU bok for arr cft ftIowinq51flS Cf a

How can you heip your thdd prevent aconcussion or other serIcius brain mnjtiry?

. Ensu that thy fc[bw thfr cach5 ruIs frth ruI cf ti sport

. Encurg thm to prcLic oc a aLl Urr.

. t1ik ur th wr th rjht prcbcti qurnnt fthiYi actkt Ptct’ie uipmint shud fit TroP[

b wR nintirtd. Wrt:n;; a h[mnt is a mu5t t rdu th tik of a 5iicu5

brn injury cm skult fractur.— Hci€r, ri[mt ar nt’t dini tc pr€it

cnrussicn5* Tht is cn:u5icn-p:of’ hiLi,t.sn.. ien witr. hI.mt it inpcdar t fr ki nitns to aToid hts ft id.

What sliciuld you do if you think roor childhas a coiictission?5EK MDI(AL AUNflON R]G4T AWAY. 1 tth crpfssicnaI i[L b able b eci how teCflCli5Sffl i ni whi it is 5ft for cur child t return fttiçu1t actMff%.. inc[udn; spcits

KEEP YOUR CHIlD OUT CF PLAY. ncuiois :ak tirn thL Dit [t ur child rurn t pL th d th fnjuand until a ha[th care rofs5iona[ sa its ChiL:ren whorturn t ;L too &on—whiI th brain [5 still haUnq—ñsk a grafti chance o havin a rpat concuin. Rpa:o [aftr CoflCu55iofl5 fl b v&’,’ rious. Th :a caupirrnnnt brain damage. affecting your chiLd for a [iftturm.

T[LL YOUR (HILlY’S COAtH ABOUT ANY PREVIOUSCONCUS5ION achs shQuid kn:w if ur chii ha’] apTvu5 concussion. YDur r1ds coa:h na not knD abouta concus5on ur c[d rcR€d anoter rt or adRiturtt5s ou t&I th :cch.

If you thialk your teen has a concussion:DoWt S5€5S it youreIf hke hirn/er out ol ptaySeek the .d’qce of a h€afth cane prcfessimiaL

It’s beffer to miss one qcirne flimi the whcIe season.Fo more information ‘it wwwcdc.gov/Concuscion,

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SYMPTOMS REPOT[D SIGNS OBSERVID BYBY ATHLETE PAR[NT3/GUARDIANS

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. Nusa or miting

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. Snsihvity to Light

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. Forgets anWstruction

* Is unsure of game,5C0te, or pponent

. rkw5 :tumsi[4 Feeling s[u;gst;.har fo;gy, orrcgy

. :‘icntaticn ornencry pb[ews

. Ar7:wer que5tins

. Lose5 :nscicusnes5(ee brieflyl

. nft5ion4 Just no fta[in ñh’

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Show5bhair, ctpr%]a[iI chans

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SUDDEN CARDIAC ARRESTA Fact Sheetfor Student Athietes

FACTSSudden cardiac arrest can occur even inathletes who are in peak shape. Approximately500 deaths are attributed to sudden cardiacarrest in athletes each year in the United States.Sudden cardiac arrest can affect all levels ofathletes, in all sports, and in all age levels. Themajority olcardiac arrests are due to congenital(inherited) heart defects. However, suddencardiac arrest can also occur after a personexperiences an illness which has caused aninflammation to the heart or after a direct blowto the chest. Once a cardiac arrest occurs,there is very little time to save the athlete, soidentifying those at risk before the arrest occursis a key factor in prevention.

WARNING SIGNSThere may not be any noticeable symptomsbefore a person experiences loss ofconsciousness and a full cardiac arrest (no pulseand no breathing).

Warning signs can include a complaint of:. Chest Discomfort. Unusual Shortness of Breath. Racing or Irregular Heartbeat. Fainting or Passing Out

EMERGENCY SIGNS — Call EMS (911)If a person experiences any of the followingsigns, call EMS (911) immediately:

. If an athlete collapses suddenly duringcompetition

. Ifa blow to the chestfrom a ball, puckor another player precedes an athlete’scomplaints ofany ofthe warning signsofsudden cardiac arrest

. If an athlete does not look orfeel rightand you arejust not sure

How can I help prevent a sudden cardiacarrest?Daily physical activity, proper nutrition, andadequate sleep are all important aspects of life-long health. Additionally, you can assist by:

. Knowing if you have a family history ofsudden cardiac arrest (onset of heartdisease in a family member before theage of 50 or a sudden, unexplaineddeath at an early age)

. Telling your health care provider duringyour pre-season physical about anyunusual symptoms of chest discomfort,shortness of breath, racing or irregularheartbeat, or feeling faint, especially ifyou feel these symptoms with physicalactivity

. Taking only prescription drugs that areprescribed to you by your health careprovider

. Being aware that the inappropriate useof prescription medications or energydrinks can increase your risk

. Being honest and reporting symptomsof chest discomfort, unusual shortnessof breath, racing orirregular heartbeat,or feeling faint

What should I do if I think I am developingwarning signs that may lead to sudden cardiacarrest?

1. Tell an adult — your parent or guardian,your coach, your athletic trainer or yourschool nurse

2. Get checked out by your health careprovider

3. Take care ofyour heart4. Remember that the most dangerous thing

you can do is to do nothing

Developed and Reviewed by the Indiana Department ofEducation’s Sudden Cardiac Arrest Advisory Board

(1-7-15)

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SUDDEN CARDIAC ARRESTA fact Sheetfor Parents

FACTSSudden cardiac arrest is a rare, but tragic eventthat claims the lives of approximately 500athletes each year in the United States. Suddencardiac arrest can affect all levels of athletes, inall sports, and in all age levels. The majority ofcardiac arrests are due to congenital (inherited)hea rt defects. H oweve r, su dde n ca rd iac arrestcan also occur after a person experiences anillness which has caused an inflammation to theheart or after a direct blow to the chest.

WARNING SIGNSThere may not be any noticeable symptomsbefore a person experiences loss ofconsciousness and a full cardiac arrest (no pulseand no breathing).

Warning signs can include a complaint of:. Chest Discomfort. Unusual Shortness of Breath. Racing or Irregular Heartbeat. Fainting or Passing Out

EMERGENCY SIGNS — Call EMS (911)If a person experiences any of the followingsigns, call EMS (911) immediately:

. If an athlete collapses suddenly duringcompetition

. Ifa blow to the chestfrom a ball, puckor another player precedes an athlete’scomplaints of any of the warning signsofsudden cardiac arrest

. Ifan athlete does not look orfeel rightand you arejust not sure

Developed and Reviewed by the Indiana Department ofEducabon’s Sudden Cardiac Arrest Advisory Board(1-7-15)

How can I help my child prevent a suddencardiac arrest?Daily physical activity, proper nutrition, andadequate sleep are all important aspects of life-long health. Additionally, parents can assiststudent athletes prevent a sudden cardiacarrest by:

. Ensuring your child knows about anyfamily history of sudden cardiac arrest(onset of heart disease in a familymember before the age of 50 or asudden, unexplained death at an earlyage)

. Ensuring your child has a thorough preseason screening exam prior toparticipation in an organized athleticactivity

. Asking ifyour school and the site ofcompetition has an automaticdefibrillator (AED) that is close by andproperly maintained

. Learning CPR yourself

. Ensuring your child is not using anynon-prescribed stimulants orperformance enhancing drugs

. Being aware that the inappropriate useof prescription medications or energydrinks can increase risk

. Encouraging your child to be honestand report symptoms of chestdiscomfort, unusual shortness ofbreath, racing or irregular heartbeat, orfeeling faint

What should I do if I think my child haswarning signs that may lead to sudden cardiacarrest?

1. Tell your child’s coach about any previousevents orfamily history

2. Keep your child out ofplay3. Seek medical attention tight away

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