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Student-Athlete & Parent/Legal Guardian Concussion Statement

Please review the MHSA forms and then complete the questions below. Required fields marked with an asterisk *

MHSA Concussion Statment and Educational Information

Student-Athlete & Parent/Legal Guardian Concussion Statement

Because of the passage of the Dylan Steigers’ Protection of Youth Athletes Act, schools are required to distribute information sheets for the purpose of informing and educating student-athletes and their parents of the nature and risk of concussion and head injury to student athletes, including the risks of continuing to play after concussion or head injury. Montana law requires that each year, before beginning practice for an organized activity, a student-athlete and the student-athlete’s parent(s)/legal guardian(s) must be given an information sheet, and both parties must sign and return a form acknowledging receipt of the information to an official designated by the school or school district prior to the student-athletes participation during the designated school year. The law further states that a student-athlete 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. 

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We have read the Student-Athlete & Parent/Legal Guardian Concussion Information Sheet (above). (If true, please check box)*
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After reading the information sheets above, I am aware of the following information:*
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Student Athlete Acknowledgement
Parent/Legal Guardian Acknowledgement
A concussion is a brain injury, which should be reported to my parents, my coach(es), or a medical professional if one is available.
A concussion can affect the ability to perform everyday activities such as the ability to think, balance, and classroom performance.
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 tell my parents, my coach, and/or a medical professional about my injuries and illnesses.
If I think a teammate has a concussion, I should tell my coach(es), parents, or licensed health care professional about the concussion
I will not return to play in a game or practice if a hit to my head or body causes any concussion-related symptoms.
I will/my child will need written permission from a licensed health care professional to return to play or practice after a concussion.
After a concussion, the brain needs time to heal. I understand that I am/my child is much more likely to have another concussion or more serious brain injury if return to play or practice occurs before concussion symptoms go away.
Sometimes, repeat concussions can cause serious and long-lasting problems.
I have read the concussion symptoms on the Concussion fact sheet.
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