<p> Los Angeles Mission College Injury and Illness Reporting Acknowledgement Form</p><p>I, ______, acknowledge that I have to be an active participant in my own healthcare. As such, I have the direct responsibility for reporting all of my injuries and illnesses to the sports medicine staff at Los Angeles Mission College (e.g., team physician, athletic training staff). </p><p>I recognize that my true physical condition is dependent upon an accurate medical history and a full disclosure of any symptoms, complaints, prior injuries and/or disabilities experienced. I hereby affirm that I have fully disclosed in writing any prior medical conditions and will also disclose any future conditions to the sports medicine staff at my institution. </p><p>I am familiar with the policies and procedures of the athletic training room at Los Angeles Mission College and the student insurance coverage provided by the Los Angeles Community College District.</p><p>I further understand that there is a possibility that participation in my sport may result in a head injury and/or concussion. I have been provided with education on head injuries and understand the importance of immediately reporting symptoms of a head injury/concussion to my sports medicine staff.</p><p>By signing below, I acknowledge that the Los Angeles Mission College athletic training staff has provided me with detailed information regarding the policies and procedures of athletics, specific educational materials on what is a concussion and given me an opportunity to ask questions about areas and issues that are not clear to me.</p><p>I, ______have read the above and agree that the statements are accurate. Printed name of Student-Athlete</p><p>______Signature of Student-Athlete Date LOS ANGELES COMMUNITY COLLEGES 770 WILSHIRE BOULEVARD, LOS ANGELES, CALIFORNIA 90017 • 213/891-2000 CITY • EAST • HARBOR • MISSION • PIERCE • SOUTHWEST • TRADE-TECHNICAL • VALLEY • WEST ADMINISTRATIVE OFFICES </p><p>Los Angeles Mission College Student-Athlete Concussion Statement □ I understand that it is my responsibility to report all injuries and illnesses to my athletic trainer and/or team physician. □ I have read and understand the NCAA Concussion Fact Sheet.</p><p>□ I watched the Second Impact video After reading the NCAA Concussion fact sheet, I am aware of the following information: ______A concussion is a brain injury, which I am responsible for reporting to my Initial team physician or athletic trainer. ______A concussion can affect my ability to perform everyday activities, and Initial affect reaction time, balance, sleep, and classroom performance. ______You cannot see a concussion, but you might notice some of the symptoms Initial right away. Other symptoms can show up hours or days after the injury. ______If I suspect a teammate has a concussion, I am responsible for reporting Initial the injury to my team physician or athletic trainer. ______I will not return to play in a game or practice if I have received a blow to Initial the head or body that results in concussion-related symptoms. ______Following concussion the brain needs time to heal. You are much more Initial likely to have a repeat concussion if you return to play before your symptoms resolve. ______In rare cases, repeat concussions can cause permanent brain damage, Initial and even death.</p><p>______Signature of Student-Athlete Date</p><p>______Printed name of Student-Athlete</p><p>______Parent/Guardian Signature (If under 18 years of age) Date</p>