Jerome Joint School District No. 261

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: 07/24/2012