2019-20 Athletic Physical and Authorization


Please select all the sports your child will be participating in this school year.

All students participating in athletics at Charlotte Christian School must have active health care coverage. Please provide the policy number and insurance carrier name:

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Concussion Information

What is a Concussion?

A concussion is a traumatic brain injury caused by a direct or indirect impact to the head that results in disruption of normal brain function, which may or may not result in loss of consciousness. It can occur from a fall, a blow to the head, or a blow to the body that causes the head and the brain to move quickly back and forth.


How do I recognize a concussion?

There are many signs and symptoms a person may experience following concussion that can affect their thinking, emotions or mood, physical abilities, or sleep.
  • Physical - Headache Fuzzy or blurry vision Nausea/Vomiting Dizziness Balance problems Sensitivity to noise or light
  • Thinking/Remembering - Difficulty thinking clearly Feeling slowed down Difficulty concentrating Difficulty remembering new information
  • Mood/Emotional - Irritability Sadness More emotional than normal Feeling nervous or anxious Crying more
  • Sleep - Sleeping more than usual Sleeping less than usual Trouble falling asleep


What should I do if I think a student-athlete has sustained a concussion?

If you suspect a student-athlete is experiencing any of the signs and symptoms listed above, you immediately remove them from participation, let their parents know, and/or refer them to the appropriate medical personnel.

What are the warning signs that a more significant head injury may have occurred?

If they have a headache that gets worse over time, experience loss of coordination or abnormal body movements, have repeated nausea, vomiting, slurred speech, or you witness what you believe to be a severe head impact, you should refer them to appropriate medical personnel immediately.

What are some of the long-term or cumulative issues that may result from a concussion?

Individuals may have trouble in some of their classes at school or even with activities at home. Down the road, especially if their injury is not managed properly, or if they return to play too early, they may experience issues such as being depressed, not feeling well, or have trouble remembering things for a long time. Once an individual has a concussion, they are also more likely to sustain another concussion.

How do I know when it’s ok for a student-athlete to return to participation after a suspected concussion?

Any student-athlete experiencing signs and symptoms consistent with a concussion should be immediately removed from play or practice and referred to appropriate medical personnel. They should not be returned to play or practice on the same day. To return to play or practice, they will need written clearance from a medical professional trained in concussion management.

No athlete should be returned to play or practice while experiencing any concussion-related signs or symptoms following rest or activity.

This information is provided to you by the UNC Matthew Gfeller Sport-Related TBI Research Center, North Carolina Medical Society, North Carolina Athletic Trainers’ Association, Brain Injury Association of North Carolina, North Carolina Neuropsychological Society, and North Carolina High School Athletic Association.

Please read the following questions and initial at the end.

  • A concussion can affect a student-athlete’s ability to perform everyday activities, their ability to think, their balance, and their classroom performance.
  • A concussion is a brain injury.
  • I realize I cannot see a concussion, but I might notice some of the signs in a student-athlete right away. Other signs/symptoms can show-up hours or days after the injury.
  • A concussion is a brain injury, which should be reported to my parents, my coach(es), or a medical professional if one is available.
  • I will tell my parents, my coach, and/or a medical professional about my injuries and illnesses.
  • If I think a teammate has a concussion, I should tell my coach(es), parents, or medical professional about the concussion.
  • I will not return to play in a game or practice if a hit to my head or body causes any concussion-related symptoms.
  • I realize that ER/Urgent Care physicians will not provide clearance if seen right away after the injury.
  • I will/my child will need written permission from a medical professional trained in concussion management to return to play or practice after a concussion.
  • Based on the latest data, most concussions take days or weeks to get better. A concussion may not go away right away. I realize that resolution from this injury is a process and may require more than one medical evaluation.
  • After a concussion, the brain needs time to heal. I understand that I am/my child is much more likely to have another concussion or more serious brain injury if return to play or practice occurs before concussion symptoms go away.
  • Sometimes, repeat concussions can cause serious and long-lasting problems.
  • I have read the concussion symptoms on the Concussion Information Sheet.

Duty to Warn Statement

Charlotte Christian Athletic Department Catastrophic Warning Statement

By its nature, participation in interscholastic athletics includes risk of injury which may range in severity from minor to disabling, the possibility of paralysis in certain activities, to even death. Although serious injuries are not common in supervised athletic programs, it is impossible to eliminate the risk. Participants can and have the responsibility to help reduce the chance of injury. Participants must obey all safety rules, report all physical problems/concerns to their coaches, follow a proper conditioning program, and inspect their own equipment.

I/We the parent(s) or legal guardian(s) of the below named minor do hereby authorize participation in athletics and appoint a Charlotte Christian School representative to act in my/our behalf in authorizing unexpected medical, dental, surgical and/ or hospitalization for the below named minor during our absence within the 2019-20 athletic year.

Medical Release to Treat/Authorization for Medical Treatment

In the event of a medical emergency during my absence, I authorize Charlotte Christian School to proceed with emergency medical services deemed necessary for my child. As a student-athlete in Charlotte Christian School they may, from time to time, require treatment for illness or injury. In the interest of providing quality health care in a timely and efficient manner for said student athlete, the undersigned do hereby authorize the duly constituted agents and employees of Charlotte Christian School to obtain for said student athlete emergent or urgent medical services of whatever type or kind are deemed to be necessary for the benefit and well being of said student athlete, including care provided by the school’s certified athletic trainer. It is understood and agreed that the agents or employees of Charlotte Christian are hereby authorized to obtain medical care and treatment of the herein named student athlete, and in the event surgery is required, shall attempt by reasonable means of communication to contact the next of kin of the herein named student athlete prior to authorizing such surgery. It is understood and agreed, however, that in the event the next of kin of said student athlete are unavailable or cannot be present to authorize such surgery and related treatment, by execution of this agreement, the said next of kin of the herein named student athlete do hereby authorize the duly constituted agents and employees of Charlotte Christian School to request and authorize surgery and related medical treatment for said student athlete. It is further understood and agreed that the undersigned hereby grant to the duly constituted agents and employees of Charlotte Christian School sole discretion in the selection of medical doctors, clinics or hospital for the treatment of said student athlete in the event of an emergency.

Digital Signature Acknowledgement - Type the name of the student in the box below.
Electronic Signature (eSignature): You consent and agree that your use of a key pad, mouse or other device to select an item, button, icon or similar act/action while using any electronic form we offer; or in accessing or making any transactions regarding any document, agreement, acknowledgement, consent, term, disclosure, or condition constitutes your signature, acceptance and agreement as if actually signed by you in writing. Further, you agree that no certification authority or other third party verification is necessary to validate your electronic signature; and that the lack of such certification or third party verification will not in any way affect the enforceability of your signature or resulting contract between you and Charlotte Christian School. You understand and agree that your eSignature executed in conjunction with the electronic submission of your form will be legally binding and such transaction will be considered authorized by you.
Digital Signature Acknowledgement - Type the name of the parent in the box below.
Electronic Signature (eSignature): You consent and agree that your use of a key pad, mouse or other device to select an item, button, icon or similar act/action while using any electronic form we offer; or in accessing or making any transactions regarding any document, agreement, acknowledgement, consent, term, disclosure, or condition constitutes your signature, acceptance and agreement as if actually signed by you in writing. Further, you agree that no certification authority or other third party verification is necessary to validate your electronic signature; and that the lack of such certification or third party verification will not in any way affect the enforceability of your signature or resulting contract between you and Charlotte Christian School. You understand and agree that your eSignature executed in conjunction with the electronic submission of your form will be legally binding and such transaction will be considered authorized by you.

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