player ​CONCUSSION AND SUDDEN CARDIAC ARREST ACKNOWLEDGEMENT AND SIGNATURE FORM FOR PARENTS AND players participating in ultimate frisbee

    The Center Grove Ultimate Club, Inc. (CGUC) acknowledges and follows Indiana state law (IC 20-34-7)  “Student Athletes: Concussions and Head Injuries”, to distribute information sheets to inform and educate student athletes and their parents of the nature and risk of concussion, head injury and sudden cardiac arrest to student athletes, including the risks of continuing to play after concussion or head injury.  The law requires that each year, before beginning practice for an interscholastic or intramural sport, a high school student athlete and the student athlete’s parents must be given an information sheet, and both must sign and return a form acknowledging receipt of the information to the student athlete’s coach.  The law further states that a high school athlete who is suspected of sustaining a concussion or head injury in a practice or game, shall be removed from play at the time of injury and may not return to play until the student athlete has received a written clearance from a licensed health care provider trained in the evaluation and management of concussions and head injuries.

    IC 20-34-8 states that a student athlete who is suspected of experiencing symptoms of sudden cardiac arrest shall be removed from play and may not return to play until the coach has received verbal permission from a parent or legal guardian of the student athlete to return to play. Within twenty-four (24) hours, this verbal permission must be replaced by a written statement from the parent or guardian.

    Parent/Legal Guardian - please read the fact sheets regarding concussion and sudden cardiac arrest and ensure that your student athlete has also received and read these fact sheets. After reading these fact sheets, please ensure that you and your student athlete sign this form below.

    Heads Up – Concussion in High School Sports – A Fact Sheet for Parents
    Heads Up – Concussion in High School Sports – A Fact Sheet for Athletes
    Sudden Cardiac Arrest - A Fact Sheet for Parents
    Sudden Cardiac Arrest - A Fact Sheet for Athletes
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    I, as a student athlete, have received and read both of the fact sheets regarding concussion and sudden cardiac arrest. I understand the nature and risk of concussion and head injury to student athletes, including the risks of continuing to play after concussion or head injury, and the symptoms of sudden cardiac arrest. 
     I, as the parent or legal guardian of the above named student athlete, have received and read both of the fact sheets regarding concussion and sudden cardiac arrest. I understand the nature and risk of concussion and head injury to student athletes, including the risks of continuing to play after concussion or head injury, and the symptoms of sudden cardiac arrest.
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Center Grove Ultimate Club - Founded (2003) - Incorporated (2014)
​PO Box 1406, Greenwood, IN 46142