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West MS (5-8th) Lacrosse Fall 2025

PLAYER INFORMATION
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PARENT/GUARDIAN #1

PARENT/GUARDIAN #2

MEDICAL/EMERGENCY CONTACT INFORMATION

WAIVER INFORMATION
DISCLAIMER, ASSUMPTION OF RISK AND WAIVER:
To accept registration and permit participation in Knox County programs by the named participant, I the parent or guardian of said participant, hereby give my consent and agree to release, indemnify, and hold harmless Knox County, its officials, coaches, representatives and volunteers from any claim arising out of injury to the named participant. I acknowledge that Knox County does not provide medical insurance of any kind to participants.
For myself and on behalf of my heirs, assigns and next of kin, I acknowledge that participation in this program may include travel, participation on adverse field conditions, and risk of physical injury or death. For myself and on behalf of my heirs, assigns and next of kin, I willingly and voluntarily accept and assume all such risks of participation. I hereby release, discharge and agree to hold harmless Knox County, its employees, volunteers, officials, sponsors and other representatives from any and all claims, demands, costs, expenses and compensation arising out of or in any way related to any injury or other damage that may result to the participant while participating in this Knox County sponsored activity. I have read and agree to abide by the Knox County Sports Code of Conduct.
Cardiac Form: Please read with player
Athlete/Parent/Guardian Sudden Cardiac Arrest Symptoms and Warning Signs Information Sheet and Acknowledgement of Receipt and Review Form

What is sudden cardiac arrest?
Sudden cardiac arrest (SCA) is when the heart stops beating, suddenly and unexpectedly. When this happens, blood stops flowing to the brain and other vital organs. SCA doesnt just happen to adults; it takes the lives of students, too. However, the causes of sudden cardiac arrest in students and adults can be different. A youth athletes SCA will likely result from an inherited condition, while an adults SCA may be caused by either inherited or lifestyle issues.
SCA is NOT a heart attack. A heart attack may cause SCA, but they are not the same. A heart attack is caused by a blockage that stops the flow of blood to the heart. SCA is a malfunction in the hearts electrical system, causing the heart to suddenly stop beating.

How common is sudden cardiac arrest in the United States?
SCA is the #1 cause of death for adults in this country. There are about 300,000 cardiac arrests outside hospitals each year. About 2,000 patients under 25 die of SCA each year. It is the #1 cause of death for student athletes.

Are there warning signs?
Although SCA happens unexpectedly, some people may have signs or symptoms, such as:
-fainting or seizures during exercise;
-unexplained shortness of breath;
-dizziness;
-extreme fatigue;
-chest pains; or
-racing heart.

These symptoms can be unclear in athletes, since people often confuse these warning signs with physical exhaustion. SCA can be prevented if the underlying causes can be diagnosed and treated.

What are the risks of practicing or playing after experiencing these symptoms?
There are risks associated with continuing to practice or play after experiencing these symptoms. When the heart stops, so does the blood that flows to the brain and other vital organs. Death or permanent brain damage can occur in just a few minutes. Most people who experience SCA die from it. Public Chapter 325 the Sudden Cardiac Arrest Prevention Act
The act is intended to keep youth athletes safe while practicing or playing. The requirements of the act are:

-All youth athletes and their parents or guardians must read and sign this form. It must be returned to the school before participation in any athletic activity. A new form must be signed and returned each school year.

Adapted from PA Department of Health: Sudden Cardiac Arrest Symptoms and Warning Signs Information Sheet and Acknowledgement of Receipt and Review Form. 7/2013
-The immediate removal of any youth athlete who passes out or faints while participating in an athletic activity, or who exhibits any of the following symptoms:
(i) Unexplained shortness of breath;
(ii) Chest pains;
(iii) Dizziness
(iv) Racing heart rate; or
(v) Extreme fatigue; and
-Establish as policy that a youth athlete who has been removed from play shall not return to the practice or competition during which the youth athlete experienced symptoms consistent with sudden cardiac arrest
-Before returning to practice or play in an athletic activity, the athlete must be evaluated by a Tennessee licensed medical doctor or an osteopathic physician. Clearance to full or graduated return to practice or play must be in writing.

I have reviewed and understand the symptoms and warning signs of SCA.
CONCUSSION INFORMATION AND SIGNATURE FORM
FOR STUDENT-ATHLETES & PARENTS/LEGAL GUARDIANS
(Adapted from CDC Heads Up Concussion in Youth Sports)
Public Chapter 148, effective January 1, 2014, requires that school and community organizations sponsoring youth athletic activities establish guidelines to inform and educate coaches, youth athletes and other adults involved in youth athletics about the nature, risk and symptoms of concussion/head injury.
Read and keep this page.
by initialing the box at the end of this form states that you and your players understand all of the concussion information and steps required for the concussion protocol.
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 rapidly 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.
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.
WHAT ARE THE SIGNS AND SYMPTOMS OF 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 listed below after a bump, blow or jolt to the head or body, s/he should be kept out of play the day of the injury and until a health care provider* says s/he is symptom-free and its OK to return to play.
SIGNS OBSERVED BY COACHING STAFF
SYMPTOMS REPORTED BY ATHLETES
Appears dazed or stunned
Headache or pressure in head
Is confused about assignment or position
Nausea or vomiting
Forgets an instruction
Balance problems or dizziness
Is unsure of game, score or opponent
Double or blurry vision
Moves clumsily
Sensitivity to light
Answers questions slowly
Sensitivity to noise
Loses consciousness, even briefly
Feeling sluggish, hazy, foggy or groggy
Shows mood, behavior or personality changes
Concentration or memory problems
Can?t recall events prior to hit or fall
Confusion, Just not feeling right or feeling down
*Health care provider means a Tennessee licensed medical doctor, osteopathic physician or a clinical neuropsychologist with concussion training
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 after a bump, blow or jolt to the head or body if s/he exhibits any of the following danger signs:
-One pupil larger than the other
-Is drowsy or cannot be awakened
-A headache that not only does not diminish, but 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)
WHY SHOULD AN ATHLETE REPORT HIS OR HER SYMPTOMS?
If an athlete has a concussion, his/her brain needs time to heal. While an
athletes 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 brains. They can even be fatal.
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.
WHAT SHOULD YOU DO IF YOU THINK YOUR ATHLETE HAS A CONCUSSION?
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 provider* says s/he is symptom-free and its OK to return to play. 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 or 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.* Health care provider means a Tennessee
licensed medical doctor, osteopathic physician or a clinical neuropsychologist with concussion training.
Student-athlete & Parent/Legal Guardian Concussion Statement
Must be signed and returned to school or community youth athletic activity prior to participation in practice or play.
Student-Athlete Name: _________________________________________________________
Parent/Legal Guardian Name(s): _________________________________________________
After reading the information sheet, I am aware of the following

A concussion is a brain injury which should be reported to my
parents, my coach(es) or a medical professional if one is available.
A concussion cannot be seen. Some symptoms might be present
right away. Other symptoms can show up hours or days after an
injury.
I will tell my parents, my coach and/or a medical professional about
my injuries and illnesses.

I will not return to play in a game or practice if a hit to my head or
body causes any concussion-related symptoms.

I will/my child will need written permission from a health care
provider* to return to play or practice after a concussion.
Most concussions take days or weeks to get better. A more serious
concussion can last for months or longer.
After a bump, blow or jolt to the head or body an athlete should
receive immediate medical attention if there are any danger signs
such as loss of consciousness, repeated vomiting or a headache
that gets worse.
After a concussion, the brain needs time to heal. I understand that I
am/my child is much more likely to have another concussion or
more serious brain injury if return to play or practice occurs before
the concussion symptoms go away.
Sometimes repeat concussion can cause serious and long-lasting
problems and even death.
I have read the concussion symptoms on the Concussion
Information Sheet. Health care provider means a Tennessee licensed medical doctor, osteopathic physician or a clinical
neuropsychologist with concussion training

Again, by checking the box below you are agreeing that you have read, along with your player, ALL of the information above and agree to take steps required to insure that all rules are followed.
 

* indicates required fields