Player Medical Release and Concussion Form

As the parent/legal guardian of _________________________________________, I request that in my absence the above named player be admitted to any hospital or medical facility for diagnosis and treatment. I request and authorize physicians, dentists and staff, duly licensed as Doctors of Medicine or Doctors of Dentistry or other such licensed technicians or nurses, to perform any diagnostic procedures, treatment procedures, operative procedures and x-ray treatment to the above minor. I have not been given a guarantee as to the results of any examination or treatment. I authorize the hospital or medical facility to dispose of any specimen or tissue taken from the above named player

Date of Player's Birth * +

Date of last tetanus booster * +

Known allergies of the player, including any allergies to medicine *

Any other medical problems that should be notes (such as previous concussions) *

Family Physician *

Phone Number *

Name of Parent or Guardian

First Name *

Last Name *

Street Address *

Address Line 2

City *

State *

Zip Code *

Phone Number *

Person responsible for medical charges (if different from above)

First Name

Last Name

Street Address

Address Line 2

City

State

Zip Code

Phone Number

Person to notify if parent/guardian is unavaiable

First Name *

Last Name *

Street Address *

Address Line 2

City *

State *

Zip Code *

Phone Number *

Insurance Carrier *

Policy # *

Signature of Parent/Guardian *

by checking the box I understand that this is my signature

Concussion Form

General Concussion Policy
The Utah High School Lacrosse League Concussion Management policy requires that a player be removed from a practice or game if he or she is suspected of sustaining a concussion or a traumatic head injury. The full policy can be found at www.utahlax.org . Furthermore, that player will not be permitted to return to play until he/she has been evaluated and cleared (in writing) by a qualified health care professional, trained in the evaluation and management of a concussion (per H.B. 204 -http://le.utah.gov/~2011/bills/hbillenr/hb0204.pdf ).

Baseline Testing

Players are strongly encouraged to seek out a reputable professional to provide baseline testing. Baseline testing can help with the diagnosis of a concussion and assist with determining when an athlete is ready to resume play. It is HIGHLY recommended but not required.

Resources

Valuable training resources have been provided by US Lacrosse and The Center for Disease Control and links to that information is available on the Utah Lacrosse Association’s website: https://leagueathletics.com/Page.asp?n=67466&org=utahlax.org

Acknowledgement

I hereby acknowledge:
- I have read and reviewed the UHSLL concussion policy and understand the requirements as dictated by House Bill 204.
- I will remove my child from practice or play if they sustain any head injury (bump, blow, jolt to head)
- My child will not be returned to play until they have been cleared (in writing) by a qualified health care professional

Signature of Parent/Guardian *

by checking box I understand that this is my signature