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Concussion Acknowledgment and Signature Form

  • All students who participate in athletics at Delphi Consolidated School Corporation and their parent must complete this form. This form is intended to be completed simultaneously by both the parent and the student-athlete. This form should be completed before the athlete participates in a sport. In addition to this online form, an athletic physical must be completed and turned in to the athletic office prior to the start of practice.
  • Due to the new law “Student Athletes: Concussions and Head Injuries” (IC 20-34-7), schools are now required to distribute information sheets to inform and educate 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. The law requires that each year, before beginning practice for an interscholastic or intramural sport, a high school 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. The law further states that a high school 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 trained in the evaluation and management of concussions and head injuries.

    Parent -please read the attached “Heads Up –Concussion in High School Sports –A Fact Sheet for Parents” and ensure that your child has also received and read “Heads Up –Concussion in High School Sports –A Fact Sheet for Athletes”.After reading these fact sheets, please sign below and ensure that your child also signs the form. Once signed, have your student athlete return this form to his/her coach.
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