Gooding Joint School District No. 231

 

STUDENTS                                                                                                           3505F2

 

AUTHORIZATION TO RETURN TO PLAY OR PARTICIPATE IN STUDENT SPORTS

 

I hereby state that I am a:

         Physician licensed pursuant to chapter 18, title 54, Idaho Code.

         Physician’s assistant licensed pursuant to chapter 18, title 54, Idaho Code.

         Advanced practice nurse licensed under section 54-1409, Idaho Code.

         A licensed health care professional trained in the evaluation and management of concussions who is supervised by a directing physician licensed under chapter 18, title 54, Idaho Code. My directing physician is                                , and his/her license number is

                            , and address is                             .

I further state that I have met with                                                      (hereinafter referred to as “student athlete”) to evaluate the student athlete for a concussion. I have discussed with the student athlete the potential ramifications of continuing to play sports after having received a concussion or exhibiting concussion like symptoms. I am satisfied that the student athlete can return to play and/or participate in school athletic leagues or sports without significant likelihood of danger or injury, and I therefore authorize student athlete to return to play and/or participation in school athletic leagues or sports.

Signature                                            Date                                        License No.

Address

Signature of Directing Physician       Date

(if signed by a Licensed Health Care Professional)

Policy History:

Adopted on: July 17, 2012 Revised on:

3505F2-1