West Rebels Youth Football

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.

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.

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 it’s 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

Can’t recall events after hit or fall

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
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.
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 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 brains. They can even be fatal.
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 it’s 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.

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 doesn’t 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 athlete’s SCA will likely result from an inherited condition, while an adult’s 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 heart’s 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.

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