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Concussion Reporting and Medical Clearance Form

CONCUSSION REPORTING AND MEDICAL CLEARANCE TO RETURN TO PLAY FORM

Minnesota statute §121A.37 requires that a youth athlete must be removed from physical participation in an athletic activity if they exhibit any signs, symptoms or behaviors consistent with a concussion or is suspected of sustaining a concussion and shall not return to physical activity until he or she no longer exhibits the signs, symptoms or behaviors consistent with a concussion and has been evaluated by a provider trained and experienced in managing concussions and has provided written clearance to participate in the athletic activity. This form is to be used after an athlete has been removed from an athletic activity due to a concussion or concussion symptoms.

Note: An “Appropriate health professional” means a health professional who is licensed, registered, certified or otherwise authorized to provide medical treatment, trained and experienced in evaluating and managing pediatric concussions, and practicing within that person’s medical training and scope of practice.

By submitting the form, I certify the following: * I AM THE PARENT OR LEGAL GUARDIAN OF THE PLAYER IDENTIFIED ON THIS FORM AND I CONSENT TO THEIR RETURN TO ATHLETIC ACTIVITY WITHOUT RESTRICTION. * THE ABOVE MENTIONED HEALTH PROFESSIONAL AUTHORIZES THE ABOVE NAMED ATHLETE TO RETURN TO ATHLETIC ACTIVITY FOR FULL PARTICIPATION WITHOUT RESTRICTION.

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