Desktop Schools Popup

Select a School

Series 604. - Concussion Awareness Release for High School Students to Participate in Non-Minnesota State High School League Athletic Activities


In accordance with Minnesota Statute 121A.38, District 196 is required to make the following information available to student athletes and parents about the nature and risks of concussions, including the effects of continuing to play after receiving a concussion.

As confirmation of your receipt and review of the information below, every student athlete and his/her parent/guardian must sign and return this form each year prior to student participation in athletic activities.

A concussion is a brain injury. Concussions are caused by a bump, blow, or jolt to the head or body. Even a “ding,” “getting your bell rung,” or what seems to be a mild bump or blow to the head can be serious.

You can’t see a concussion. Signs and symptoms of concussion can show up right after the injury or may not appear or be noticed until days after the injury. If your child reports one or more symptoms of concussion listed below, or if you notice the symptoms yourself, keep your child out of play and seek medical attention right away.

Signs Observed by Parents or Guardians

Symptoms Reported by Student Athlete

  • 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
  • Headache or “pressure” in head
  • Nausea or vomiting
  • Balance problems or dizziness
  • Double or blurry vision
  • Sensitivity to light or noise
  • Feeling sluggish, hazy, foggy, or groggy
  • Concentration or memory problems
  • Confusion
  • Just not “feeling right or is “feeling down”



How can you help your child prevent a concussion?

Every sport is different, but there are steps your child can take to protect themselves from concussion and other injuries.

  • Make sure they wear the right protective equipment for their activity. It should fit properly, be well maintained, and be   worn consistently and correctly.
  • Ensure that they follow their coaches' rules for safety and the rules of the sport.
  • Encourage them to practice good sportsmanship at all times.

What should you do if you think your child has a concussion?

1. Keep your child out of play. If your child has a concussion, her/his brain needs time to heal. Don’t let your child return to play the day of the injury and until a health care provider (as defined by MN Statute 121A.38), experienced in evaluating for concussion, says your child is symptom-free and it’s OK to return to play. A repeat concussion that occurs before the brain recovers from the first—usually within a short period of time (hours, days, or weeks)—can slow recovery or increase the likelihood of having long-term problems. In rare cases, repeat concussions can result in edema (brain swelling), permanent brain damage, and even death.

2. Seek medical attention right away. A health care provider experienced in evaluating for concussion will be able to decide how serious the concussion is and when it is safe for your child to return to sports.

3. Teach your child that it’s not smart to play with a concussion. Rest is key after a concussion. Sometimes athletes wrongly believe that it shows strength and courage to play injured. Discourage others from pressuring injured athletes to play. Don’t let your teen convince you that s/he’s “just fine.”

4. Tell all of your child’s coaches and the school nurse about ANY concussion. Coaches, school nurses, and other school staff should know if your child has ever had a concussion. Your child may need to limit activities while she or he is recovering from a concussion. Things such as studying, driving, working on a computer, playing video games, or exercising may cause concussion symptoms to reappear or get worse. Talk to your health care professional, as well as your child’s coaches, school nurse, and teachers. If needed, they can help adjust your child’s school activities during her/his recovery.

If you think your child has a concussion: Don’t assess it yourself. Take him/her out of play. Seek the advice of a health care provider. More information is available at


Student signature___________________________ Parent signature                                     Date__________________