Gfeller Waller NCHSAA Student- Athlete & Parent/Legal Custodian Concussion Statement Form

All required questions are notated with an asterisk (*).

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Form Requirement(s)

  • Can upload: Student
  • Can upload: Parent
  • Can upload: Staff

  • Required for Athlete Overall Approval.
  • Athlete is under 13, No Student Athlete Signature Required.
  • Parent Signature Required.
  • Staff Signature Required.
  • Use of the Previous Year Form is allowed as long as it is not expired.

  • Auto Approval: Disabled

Instructions: The student athlete and his/her parent or legal custodian, must initial beside each statement acknowledging that they have read and understand the corresponding statement. The student-athlete should initial in the left column and the parent or legal custodian should initial in the left column. Some statements are applicable only to the student-athlete and should only be initialed by the student-athlete. This form must be completed for each student-athlete, even if there are multiple student-athletes in the household.

Student-Athlete Initials Parent/Legal
A concussion is a brain injury, which should be reported to my parent(s) or legal custodian(s), my or my child's coach(es), or a medical professional if one is available.
A concussion cannot be "seen." Some signs and symptoms might be present immediately; however, other symptoms can appear hours or days after an injury.
I will tell my parents, my coach and/or a medical professional about my injuries and illnesses. Not Applicable
If I think a teammate has a concussion, I should tell my coach(es), parent(s)/ legal custodian(s) or medical professional about the concussion. Not Applicable
I, or my child, will not return to play in a game or practice if a hit to my, or my child's, head or body causes any concussion-related symptoms.
I, or my child, will need written permission from a medical professional trained in concussion management to return to play or practice after a concussion.
Based on the latest data, most concussions take days or weeks to get better. A concussion may not go away, right away. I realize that resolution from a concussion is a process that may require more than one medical visit.
I realize that ER/Urgent Care physicians will not provide clearance to return to play or practice, if seen immediately or shortly after the injury.
After a concussion, the brain needs time to heal. I understand that I or 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 listed on the Student-Athlete/ Parent Legal Custodian Concussion Information Sheet.
I have asked an adult and/or medical professional to explain any information contained in the Student-Athlete & Parent Concussion Statement Form or Information Sheet that I do not understand.

By signing below, we agree that we have read and understand the information contained in the Student-Athlete & Parent/Legal Custodian Concussion Statement Form, and have initialed appropriately beside each statement.


Student Athlete

Print Name:



Parent / Guardian

Print Name:



My signature indicates that to the best of my knowledge, my answers and information provided to the above questions are complete and correct. I understand that the information that I have provided on this form may be used for analytical and research purposes. I consent to the access and use of this data by the Cumberland County Schools, and PlanetHS, LLC.