Los Angeles Mission College s5
Los Angeles Mission College
Injury and Illness Reporting
Acknowledgement Form
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).
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.
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.
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.
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.
I, ______have read the above and agree that the statements are accurate.
Printed name of Student-Athlete
______
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
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.
□ 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.
______
Signature of Student-Athlete Date
______
Printed name of Student-Athlete
______
Parent/Guardian Signature (If under 18 years of age) Date