Coastal Cudas Football and Cheer Organization for 8U-12U players! - (Bluffton, SC)

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Coastal Cudas Registration Form

PLAYER INFORMATION

* First Name:

* Last Name:

Street:

City:

State:

Zip Code:

Home Phone:

Birthdate:

Email:

Gender:

Grade:

PARENT/GUARDIAN #1

Firstname:

Lastname:

EMail:

Home Phone:

Work Phone:

Cell Phone:

PARENT/GUARDIAN #2

Firstname:

Lastname:

Email:

Home Phone:

Work Phone:

Cell Phone:

MEDICAL/EMERGENCY CONTACT INFORMATION

Emergency Contact:

Phone:

Relationship to Player:

Insurance Carrier:

Policy #:

WAIVER/CONCUSSION INFORMATION

Mild Traumatic Brain Injury (MTBI) / Concussion
Annual Statement and Acknowledgement Form

I, said football player/cheerleader, have chosen to participate in an a sport where injuries may occur and I do understand that it is my responsibility to report all of my injuries and illnesses or suspected injuries and illnesses to the organization?s staff, including but not limited to: coaches, team physicians, and athletic training staff. I further understand and recognize that my health and safety is the most important thing and without disclosing all injuries and or illnesses, it cannot be properly determined if you are in the physical condition necessary to participate. I understand that I must provide a full and accurate medical history including any symptoms, health complaints and any prior injuries and/or disabilities I have experienced before, during or after athletic activities.
By checking below, I acknowledge:
* The Coastal Cudas Youth Football and Cheer Organization has provided me with specific educational materials including the CDC Concussion fact sheet (http://www.cdc.gov/concussion) on what a concussion is and has given me an opportunity to ask questions.
* I ACKNOWLEDGE THAT I HAVE READ THE FACT SHEET on the CDC website for Parents and Players.
* I have fully disclosed to the staff any prior medical conditions and will also disclose any future conditions.
* There is a possibility that participation in my sport may result in a head injury and/or concussion. In EXTREMELY rare cases, these concussions can cause permanent brain damage, and even death.
* A concussion is a brain injury, which I am responsible for reporting to the team physician, athletic trainer, coach, parent volunteer, or official.
* A concussion can affect my ability to perform everyday activities, and affect my reaction time, balance, sleep, and classroom performance.
* Some of the symptoms of concussion may be noticed right away while other symptoms can show up hours or days after the injury.
* If I suspect a teammate has a concussion, I am responsible for reporting the injury to the coaching staff immediately.
* I will not return to play in a game or practice if I have received a blow to the head or body that results in concussion related symptoms.
* I will not return to play in a game or practice until my symptoms have resolved AND I have written clearance to do so by a qualified health care professional.
* Following concussion, the brain needs time to heal and you are much more likely to have a repeat concussion or further damage if you return to play before your symptoms resolve.
Based on the incidence of concussion as published by the CDC football and cheer, among other sports, have been identified as high risk for concussion.
I represent and certify that I and my parent/guardian have read the entirety of this document and fully understand the contents, consequences and implications of signing this document and agree to be bound by this document.

I/WE AGREE WITH THE ABOVE *

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