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A concussion is a brain injury and all brain injuries are serious. They are caused by a bump, blow, or jolt to the

head, or by a blow to another part of the body with the force transmitted to the head. They can range from mild

t severe and can disrupt the way the brain normally works. Even though most concussion are mild, all

concussions are potentially serious and may result in complications including prolonged brain damage

and death if not recognized and managed properly. In other words, even a “ding” or a bump on the head can

be serious. You can’t see a concussion and most sports concussions occur without loss of consciousness. Signs

and symptoms of concussion may show up right after the injury or can take house or days to fully appear. If

your child reports any symptoms of concussion, or if you notice the symptoms or signs of concussion yourself,

see medical attention right away.

Adapted from the CDC and the 3

rd

International Conference on Concussion in Sport Document created 7/1/2012

Symptoms may include one or more of the following:

 Headaches

 Feeling foggy or groggy

 Irritability

 “Pressure in head”

 Drowsiness

 More emotional

 Nausea or vomiting

 Change in sleep patterns

 Confusion

 Neck pain

 Amnesia

 Concentration or memory problems

(forgetting game plays)

 Balance problems or dizziness

 “Don’t feel right”

 Repeating the same

question/comment

 Blurred, double, or fuzzy vision

 Fatigue or low energy

 Sensitivity to light or noise

 Sadness

 Feeling sluggish or slowed

down

 Nervousness or anxiety

Signs observed by teammates, parents and coaches include:

 Appears dazed

 Moves clumsily or displays

incoordination

 Can’t recall events prior to hit

 Vacant facial expression

 Answers questions slowly

 Can’t recall events after hit

 Confused about assignment

 Slurred speech

 Seizures or convulsions

 Forgets plays

 Shows behavior or

personality changes

 Any change in typical behavior or

personality

 Is unsure of game, score, or

opponent

 Loses consciousness

CONCUSSION INFORMATION

Parents that have Adobe Acrobat Pro have the option of filling form out and emailing form to Mr.

Klover at chad.klover@rc255.net. Open form, click on “open with different viewer”, open in Adobe

Acrobat Reader. Once form is filled out click on the envelope on top.

What can happen if my child keeps on playing with a concussion or returns too soon?

Athletes with the signs and symptoms of concussion should be removed from play immediately. Continuing to

play with the signs and symptoms of a concussion leaves the young athlete especially vulnerable to greater

injury. There is an increased risk or significant damage from a concussion for a period of time after that

concussion occurs, particularly if the athlete suffers another concussion before completely recovering from the

first one. This can lead to prolonged recovery, or even to severe brain swelling (second impact syndrome) with

devastating and even fatal consequences. It is well know that adolescent or teenage athletes will often fail to

report symptoms of injuries. Concussions are no different. As a result, education of administrators, coaches,

parents and students is the key to student-athlete’s safety.

If you think your child has suffered a concussion.

Any athlete even suspected of suffering a concussion should be removed from the game or practice immediately.

No athlete may return to activity after an apparent head injury or concussion, regardless of how mild it seems or

how quickly symptoms clear, without medical clearance. Close observation of the athlete should continue for

several hours. The Return-To-Play Policy of the IESA and IHSA Policy requires athletes to provide their school

with written clearance from either a physician licensed to practice medicine in all its branches or a certified

athletic trainer working in conjunction with a physician licensed to practice medicine in all its branches prior to

returning to play or practice following a concussion or after being removed from an interscholastic contest due

to a possible head injury or concussion and not cleared to return to that same contest. In accordance with state

law, all IHSA member schools are required to follow this policy.

You should also inform your child’s coach if you think that your child may have a concussion. Remember it’s

better to miss one game than miss the whole season. And when in doubt, the athlete sits out.

For current and up-to-date information on concussions you can go to:

http://www.cdc.gov/ConcussionInYouthSports/

Student-athlete Name Printed

Student-athlete Signature

Date

Parent/Guardian Printed

Parent/Guardian Signature

Date

CONCUSSION INFORMATION-CONTINUED

Student Name:________________________________________________________ Grade:______________

Birth Date:_______________________________ Home Phone Number:___________________________

Address:__________________________________________________________________________________

Parent/Guardian Name:______________________________________________________________________

Home Phone:_________________ Cell Phone:___________________ Work Phone:_____________________

Other Emergency phone numbers (if parent/guardian is unavailable)

Name

Phone Number

Reed-Custer Community Unit School district 255 WILL NOT be held responsible for injuries or accidents incurred

while participating in any school sponsored activities.

If the Parent/Guardian cannot be reached in any emergency, and if the judgment of the school authorities is immediate

medical and/or hospital attention is indicated, please indicate which hospital should your child be transported to:

_____________________________________________________________________________________________

Please list any minor ailments, physical conditions or allergies of which a coach or attending physician should be

made aware when treating your student:

EMERGENCY CONTACT INFORMATION

STUDENT INFORMATION

MEDICAL INFORMATION

REED-CUSTER MIDDLE SCHOOL

EXTRA-CURRICULAR ACTIVITY

TRANSPORTATION CHANGE REQUEST

Reed-Custer District 255U Board of Education Policy #6412 requires that all students transported

to extra-curricular events on school vehicles must return to school on the school vehicle unless

other arrangements are made by the parent/guardian and Administrative Team, prior to the event.

__________________________________ will not be riding (to the event from RCMS/back to

RCMS from the event) on a Reed-Custer District 255U vehicle because:

Going Home With:

Parent Signature: _____________________________________________ Date: ____________

___________ Approved __________ Not Approved

Administrator Signature:_________________________________________ Date: ___________

REED-CUSTER MIDDLE SCHOOL

Student Name:__________________________________________________ Grade:___________________

Please check sports that apply:

Baseball Softball Girls’ Basketball Boys’ Basketball

Wrestling Volleyball Track Cheerleading

This is to acknowledge that we have received a copy of the Reed-Custer Middle School Athletics participation

guidelines. We have read them and we understand the conditions and rules that must be followed by all

students participating in athletics at Reed-Custer Middle School.

___________________________________________________________ ____________________

Student Signature Date

___________________________________________________________ ____________________

Parent/Guardian’s Signature Date

REED-CUSTER MIDDLE SCHOOL

ATHLETIC PARTICIPATION INFORMATION

ATHLETIC HANDBOOK INFORMATION

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