SVSU Medical Waiver and Concussion Form - To be completed for participant

Example: 02/14/2015
Please list full name of athlete
Gender *


xx/xx/xxxx
(xxx) xxx-xxxx
(xxx) xxx-xxxx
(xxx) xxx-xxxx
As the parent/guardian of the camper listed above I hereby agree to the following as a condition of my child's participation in the Saginaw Valley State University (SVSU) summer camp program and related activities. I give my permission to SVSU to provide, seek, obtain or approve any routine, necessary or emergency health care during the camper's involvement in the SVSU summer camp program. I understand that this authorization is given in advance of any specific consent to any and all such diagnosis, treatment or medical care being required and is to serve as specific consent to any and all such diagnosis, treatment or hospital care which may be deemed advisable. I understand my rights under the Health Insurance Portability and Accountability Act (HIPAA) and authorize SVSU to release information as necessary for managing summer camp healthcare. I attest that a physician has examined the camper in the past twelve months and he/she was found to be in good health. I understand and agree that SVSU may in its sole discretion, decide to refuse participation by the camper based on disclosure of medical condition. I attest that currently there is no medical reason for the camper not to participate in the strenuous physical activities of the sports camp program. I acknowledge that participation in sports camp and related activities involves an inherent risk of personal injury. I assume such risk on behalf of the camper and give my permission to the camper to participate in all sports camp activities. I release and agree to hold harmless SVSU, its Board of Control, students and employees from all claims, actions, damages and liabilities for personal injury or damage relating or arising out of any sports camp activity except where the injury or damage relating to or arising out of any sports camp activity is caused by the gross negligence of the university's employees. I understand the camper will be subject to the rules and regulations of the SVSU sports camp. I understand that any person who repeatedly disobeys camp policies or procedures will be immediately expelled from the camp. I understand that by printing my name in the area below I am submitting my online signature
xx/xx/xxxx
What is a concussion? *
A concussion is a type of traumatic brain injury that changes the way the brain normally works. A concussion is caused by a bump, blow, or jolt to the head or body that causes the head and brain to move quickly back and forth. Even a ?ding," ?getting your bell rung,? or what seems to be a mild bump or blow to the head can be serious.

What are the signs and symptoms of a concussion? *
Signs and symptoms of concussion can show up right after the injury or may not appear or be noticed until days or weeks after the injury. If an athlete reports one or more symptoms of concussion after a bump, blow, or jolt to the head or body, s/he should be kept out of play the day of the injury.The athlete should only return to play with permission from a health care professional experienced in evaluating for concussion.

Symptoms reported by athletes *
? Headache or ?pressure? in head ? Nausea or vomiting ? Balance problems or dizziness ? Double or blurry vision ? Sensitivity to light ? Sensitivity to noise ? Feeling sluggish, hazy, foggy, or groggy ? Concentration or memory problems ? Confusion ? Just not ?feeling right? or is ?feeling down?

Signs observed by coaching staff *
? Appears dazed or stunned ? Is confused about assignment or position ? Forgets an instruction ? Is unsure of game, score, or opponent ? Moves clumsily ? Answers questions slowly ? Loses consciousness (even briefly) ? Shows mood, behavior, or personality changes ? Can?t recall events prior to hit or fall ? Can?t recall events after hit or fall

Did you know? *
? Most concussions occur without loss of consciousness. ? Athletes who have, at any point in their lives, had a concussion have an increased risk for another concussion. ? Young children and teens are more likely to get a concussion and take longer to recover than adults.

Concussion Danger Signs *
In rare cases, a dangerous blood clot may form on the brain in a person with a concussion and crowd the brain against the skull. An athlete should receive immediate medical attention if after a bump, blow, or jolt to the head or body s/he exhibits any of the following danger signs: ? One pupil larger than the other ? Is drowsy or cannot be awakened ? A headache that gets worse ? Weakness, numbness, or decreased coordination ? Repeated vomiting or nausea ? Slurred speech ? Convulsions or seizures ? Cannot recognize people or places ? Becomes increasingly confused, restless, or agitated ? Has unusual behavior ? Loses consciousness (even a brief loss of consciousness should be taken seriously)

What should you do if you think your athlete has a concussion? *
1. If you suspect that an athlete has a concussion, remove the athlete from play and seek medical attention. Do not try to judge the severity of the injury yourself. Keep the athlete out of play the day of the injury and until a health care professional, experienced in evaluating for concussion, says s/he is symptom-free and it?s OK to return to play. 2. Rest is key to helping an athlete recover from a concussion. Exercising or activities that involve a lot of concentration, such as studying, working on the computer, and playing video games, may cause concussion symptoms to reappear or get worse. After a concussion, returning to sports and school is a gradual process that should be carefully managed and monitored by a health care professional. 3. Remember: Concussions affect people differently. While most athletes with a concussion recover quickly and fully, some will have symptoms that last for days, or even weeks. A more serious concussion can last for months or longer.

Why should an athlete report their symptoms? *
If an athlete has a concussion, his/her brain needs time to heal.While an athlete?s brain is still healing, s/he is much more likely to have another concussion. Repeat concussions can increase the time it takes to recover. In rare cases, repeat concussions in young athletes can result in brain swelling or permanent damage to their brain.They can even be fatal.

Verification *
By checking Yes I verify that I have read and understood the above information about concussions and how they should be managed.

Concussion Educational Materials
Can be found at www.michigan.gov/sportsconcussion | and the Concussion Fact Sheet for Parents here - http://michigan.gov/documents/mdch/ParentsFactSheet_415323_7.pdf
Verification *
By clicking "yes" the parent and youth participant are acknowledging receipt of educational materials on concussions and their consequences that are provided in the links above

I understand that by printing my name in the area below I am submitting my online signature
I understand that by printing my name in the area below I am submitting my online signature
 
* = required field