Cardiac Arrest Acknowledgement Form

What is sudden cardiac arrest?
Sudden cardiac arrest (SCA) is when the heart stops beating, suddenly and unexpectedly. When this happens, blood stops flowing to the brain and other vital organs. SCA doesn’t just happen to adults; it takes the lives of students, too. However, the causes of sudden cardiac arrest in students and adults can be different. A youth athlete’sSCA will likely result from an inherited condition, while an adult’s SCA may be caused by either inherited or lifestyle issues.

SCA is NOTa heart attack. A heart attack may cause SCA, but they are not the same. A heart attack is caused by a blockage that stops the flow of blood to the heart. SCA is a malfunction in the heart’s electrical system, causing the heart to suddenly stop beating.
How common is sudden cardiac arrest in the United States?
SCA is the #1 cause of death for adults in this country. There are about 300,000 cardiac arrests outside hospitals each year. About 2,000 patients under 25 die of SCA each year. It is the #1 cause of death for student athletes.
Are there warning signs?
Although SCA happens unexpectedly, some people may have signs or symptoms, such as:
  • fainting or seizures during exercise;
  • unexplained shortness of breath;
  • dizziness;
  • extreme fatigue;
  • chest pains; or
  • racing heart.
These symptoms can be unclear in athletes, since people often confuse these warning signs with physical exhaustion. SCA can be prevented if the underlying causes can be diagnosed and treated.
What are the risks of practicing or playing after experiencing these symptoms?
There are risks associated with continuing to practice or play after experiencing these symptoms. When the heart stops, so does the blood that flows to the brain and other vital organs. Death or permanent brain damage can occur in just a few minutes. Most people who experience SCA die from it.
Public Chapter 325–the Sudden Cardiac Arrest Prevention Act
The act is intended to keep youth athletes safe while practicing or playing. The requirements of the act are:
  • All youth athletes and their parents or guardians must read and sign this form.It must be returned to the recreational or competitive club/association before participation in any athletic activity.A new form must be signed and returned each recreational or competitive soccer year(August 1-July 31).
    -Adapted fromPA Department of Health: Sudden Cardiac Arrest Symptoms and Warning Signs Information Sheet and Acknowledgement of Receipt and Review Form. 7/2013
  • The immediate removal of any youth athlete who passes out or faints whileparticipating in an athletic activity, or who exhibits any of the following symptoms:
    (i) Unexplained shortness of breath;
    (ii) Chest pains;
    (iii) Dizziness(iv) Racing heart rate; or
    (v) Extreme fatigue; and

  • Establish as policy that a youth athlete who has beenremoved from play shall not return to the practice or competition duringwhich the youth athlete experienced symptoms consistent with suddencardiac arrest
  • Before returning to practice or play in an athletic activity, the athlete must be evaluated by a Tennessee licensed medical doctor or an osteopathic physician.Clearance to full or graduated return to practice or play must be in writing.
I have reviewed and understand the symptoms and warning signs of SCA.
Clear Signature
Soccer Players Name
MM slash DD slash YYYY
Clear Signature
Parent/Guardian’s Name
MM slash DD slash YYYY

Concussion Signs and Symptoms Information Sheet

Step 1 of 2

What is a Concussion?
A concussion is a type of traumatic brain injury that changes the way the brain normally works. A concussion is caused by a bump, blow, or jolt to the head or body that causes the head and brain to move rapidly back and forth. Even a “ding,” “getting your bell rung,” or what seems to be a mild bump or blow to the head can be serious.
Did you know?
  • Most concussions occur withoutloss of consciousness.
  • Athletes who have, at any point in their lives, had a concussion have an increased risk for another concussion.
  • Young children and teens are more likely to get a concussion and take longer to recover than adults.
Signs and symptoms of concussion can show up right after the injury or may not appear or be noticed until days or weeks following the injury.

If an athlete reports one or more symptoms of concussion listed below after a bump, blow, or jolt to the head or body, the athlete should be kept out of play the day of the injury and until an approved health care provider* says the athlete is symptom-freeand it is safe to return to play.
SIGNS OBSERVED BY COACHING STAFF
Appears dazed or stunned
Is confused about assignment or position
Forgets an instruction
Is unsure of game, score, or opponent
Moves clumsily
Answers questions slowly
Loses consciousness, even briefly
Shows mood, behavior, or personality changes
Can’t recall events prior to hit or fall
Can’t recall events afterhit or fall
SYMPTOMS REPORTED BY ATHLETES
Headache or “pressure” in head
Nausea or vomiting
Balanced problems or dizziness
Double or blurry vision
Sensitivity to light
Sensitivity to noise
Feeling sluggish, hazy, foggy, or groggy
Concentration or memory problems
Confusion
Just not “feeling right,” or “feeling down”
What are the Concussion Danger Signs?
In rare cases, a dangerous blood clot may form on the brain in a person with a concussion and crowd the brain against the skull. An athlete should receive immediate medical attention after a bump, blow, or jolt to the head or body if the athlete exhibits any of the following danger signs:
  • Has one pupil larger than the other;
  • Is drowsy or cannot be awakened;
  • Has a headache that does not diminish or go away;
  • Has weakness, numbness, or decreased coordination;
  • Has repeated vomiting or nausea;
  • Has convulsions or seizures;
  • Unable to recognize people or places;
  • Becomes increasingly confused, restless, or agitated;
  • Demonstrates unusual behavior;
  • Loses consciousness (even though brief it is serious)
Remember: Concussions affect individuals differently. While most athletes with a concussion recover quickly and fully, some will have symptoms that last for days, or weeks. A more serious concussion can last for months or longer.

Why should an Athlete Report Symptoms?
If an athlete has a concussion, their brain needs time to heal. While an athlete’s brain is healing, they are more likely to have another concussion. Repeat concussions can increase the time it takes to recover. In rare cases, repeat concussions in young athletes can result in brain swelling or permanent damage to one’s brain. They (concussions) can even be fatal. What should you do if you think your Athlete has a Concussion?
If you suspect that an athlete has a concussion, remove the athlete from play and seek medical attention. Do NOT try to judge the severity of the injury yourself. Keep the athlete out of play the day of the injury and until a health care provider* says the athlete is symptom-free and is safe to return to play.

Rest is a key component to helping an athlete recover from a concussion. Exercising or activities that involve a lot of concentration such as studying, working on the computer, or playing video games may cause concussion symptoms to reappear or grow worse. Following a concussion, returning to sports and school should be a gradual process that is carefully managed and monitored by a health care professional.
*NOTE: Health Care Provider means a Tennessee licensed medical doctor, osteopathic physician, or clinical neuropsychologist with concussion training.

Parent/Guardian Consent and Player Medical Release Form

Name
MM slash DD slash YYYY
Address

EMERGENCY INFORMATION

Parent/Guardian Name:
In an emergency, when parents cannot be reached, please contact:
Additional Emergency Contacts
Name:
Home Phone:
Work Phone:
 
Please list any known allergies
Please list any other medical conditions
Player’s Physician:
PLEASE COPY BOTH SIDES OF YOUR HEALTH INSURANCE CARD AND ATTACH TO THIS FORM
Accepted file types: jpg, gif, png, pdf, Max. file size: 32 MB.
Accepted file types: jpg, gif, png, pdf, Max. file size: 32 MB.
PARENT/GUARDIAN CONSENT AND MEDICAL RELEASE
Recognizing the possibility of injury or illness, and in consideration for US Youth Soccer and members of US Youth Soccer accepting my son/daughter as a player in the soccer programs and activities of US Youth Soccer and its members (the "Programs"), I consent to my son/daughter participating in the Programs. Further, I hereby release, discharge, and otherwise indemnify US Youth Soccer, its member organizations and sponsors, their employees, associated personnel, and volunteers, including the owner of fields and facilities utilized for the Programs, against any claim by or on behalf of my player son/daughter as a result of my son's/daughter’s participation in the Programs and/or being transported to or from the Programs. I hereby authorize the transportation of my son/daughter to or from the Programs.

My player son/daughter has received a physical examination by a licensed medical doctor and has been found physically capable of participating in the sport of soccer. I have provided written notice, which is submitted in conjunction with this release and attached hereto, setting forth any specific issue, condition, or ailment, in addition to what is specified above, that my child has or that may impact my child's participation in the Programs. I give my consent to have an athletic trainer and/or licensed medical doctor or dentist provide my son/daughter with medical assistance and/or treatment and agree to be financially responsible for the reasonable cost of any such assistance and/or treatment.
Clear Signature
MM slash DD slash YYYY

Player Commitment Letter and Release of Liability

My son/daughter (player) has been offereda position withthe following soccer club. Iunderstand that to accept this offer, I,as the parent/legal guardian,must complete this Player Commitment Letter, and return it to the club leadership.
I am committed to
Select the PWYS Club you will be playing for.
for the seasonal soccer year of 2025.
By signing this Player Commitment Letter, I give the aforementioned soccer club permission to register my player with Tennessee State Soccer Association (TSSA) in the Current Seasonal Year (“Feb. 11,, 2025 through June 30, 2025”). I further understand that this Player Commitment Letter is not binding until the 30th of June, 2025. Following the 30th of June, 2025, I understand that my player is committed to the aforementioned soccer club for the Current Seasonal Year and per TSSA Policy 26, the only way my player may be removed from this commitment is through a properly executed Player Release.

I, the parent/legal guardian of the committed player, a minor, agree that the player and I will abide by the rules of the aforementioned soccer club, TSSA, United States Youth Soccer Association (USYSA), United States Soccer Federation (USSF), and its affiliated organizations and sponsors.

RELEASE OF LIABILITY FOR MINOR PARTICIPANTS

READ BEFORE SIGNING Soccer is a physical, contact sport that involves the risk of injury. I assume all risks and hazards associated with my participation. I am in proper physical condition to participate in soccergames and have no illness, disease or existing injury or physical defect that would be aggravated by my participation.

IN CONSIDERATION OF my child/ward being allowed to participate in any way insoccer games, practice and related events and activitiesand/or being transported to or from the same,the undersigned acknowledges, appreciates, and agrees that:

The risks of injury and illness (such as outbreak of any and all communicable disease, including but not limited to, the virus “severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)”, which is responsible for Coronavirus Disease (COVID-19) and/or any mutation or variation thereof; MRSA, influenza. I acknowledge that I am aware that there are risks to me of exposure to directly or indirectly arising out of, contributed to, by, or resulting from such communicable diseases) to my child from the activities involved in these programs are significant, including the potential for permanent disability and death, and while particular rules, equipment, and personal discipline may reduce these risks, the risks of serious injury and illness do exist; and,

1. FOR MYSELF, SPOUSE, AND CHILD, I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASES orothers, and assume full responsibility for my child’s participation; and,

2. I willingly agree to comply with the program’s stated and customary terms and conditions for participation. If I observe any unusual significant concern in my child’s readiness for participation and/or in the program itself, I will remove my child from the participation and bring such attention of the nearest official immediately; and,

3. I myself, my spouse, my child, and on behalf of my/our heirs, assigns, personal representatives andnext of kin, HEREBY RELEASE AND HOLD HARMLESSTennessee State Soccer Association (TSSA) and US Youth Soccer, their affiliated organizations or clubs and sponsors, their directors, officers, officials, agents,coaches, trainers, employees, volunteers, other participants, sponsoring agencies, sponsors, advertisers, and if applicable, owners and lessors of premises used to conduct the event (“Releasees”), WITH RESPECT TO ANY AND ALL INJURY, ILLNESS, DISABILITY, DEATH, or loss or damage to person or property incident to my child’s involvement or participation in these programs, WHETHER ARISING FROM THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE, to the fullest extent permitted by law.

4. I, for myself, my spouse, my child, and on behalf of my/our heirs, assigns, personal representatives and next of kin, HEREBY INDEMNIFY AND HOLD HARMLESS all the above Releasees from any and all liabilities incident to my involvement or participation in these programs, EVEN IF ARISING FROM THEIR NEGLIGENCE, to the fullest extent permitted by law.

5. I, the parent/guardian, assert that I have explained to my child/ward: the risks of the activity, his/her responsibilities for adhering to the rules and regulations, and that my child/ward understands this agreement.

I, FORMYSELF, MY SPOUSE, AND CHILD/WARD, HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT WE HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.

By signing this form, I give your club, your association, permission to register my son/daughter to play for the Tennessee State Soccer Association Current seasonal year. (August 1st-July 31st) I further understand that as a parent/legal guardian signing this document commitsmy player to this club for the seasonal year. I, (we) the parent/legal guardian of the above player, a minor, agree that the player and I (we) will abide by the rules of your club, association, district, Tennessee State Soccer Association and US Youth Soccer, its affiliated organizations and sponsors. I have read Tennessee State Soccer Association’s Policy 26 and agree to their recruiting rules.
Parent /Legal Guardian Name:(Required)
Clear Signature
MM slash DD slash YYYY
Player Name:(Required)
MM slash DD slash YYYY
Clear Signature
MM slash DD slash YYYY

Release of Liability for Minors

Step 1 of 2

My player has been offered a position with the below noted soccer club. I understand that to accept this offer, I, as the parent/legal guardian, must complete this Player Commitment Letter, and return it to the club leadership. I am committed to Play Where You Stay for the seasonal soccer year of 2025. By signing this Player Commitment Letter, I give Play Where You Stay to register my player with the Tennessee State Soccer Association (TSSA) in the Current Seasonal Year (August 1, 2025 through July 31, 2025). I further understand that this Player Commitment Letter is not binding until the 13th of June, 2025. Following the 13th of June, 2025, I understand that my player is committed to the aforementioned soccer club for the Current Seasonal Year and per TSSA Policy 26, the only way my player may be released from this commitment is through a properly executed Player Release. I, the parent/legal guardian of the committed player, a minor, agree that the player and I will abide by the rules of the aforementioned soccer club, TSSA, United States Youth Soccer Association (USYSA), United States Soccer Federation (USSF), and its affiliated organizations and sponsors.
RELEASE OF LIABILITY FOR MINOR PARTICIPANTS - READ BEFORE SIGNING Soccer is a physical, contact sport that involves the risk of injury. I assume all risks and hazards associated with my participation. I am in proper physical condition to participate in soccer games and have no illness, disease or existing injury or physical defect that would be aggravated by my participation. IN CONSIDERATION OF my child/ward being allowed to participate in any way in soccer games, practice and related events and activities and/or being transported to or from the same, the undersigned acknowledges, appreciates, and agrees that: The risks of injury and illness (such as outbreak of any and all communicable disease, including but not limited to, the virus “severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)”, which is responsible for Coronavirus Disease (COVID-19) and/or any mutation or variation thereof; MRSA, influenza. I acknowledge that I am aware that there are risks to me of exposure to directly or indirectly arising out of, contributed to, by, or resulting from such communicable diseases) to my child from the activities involved in these programs are significant, including the potential for permanent disability and death, and while particular rules, equipment, and personal discipline may reduce these risks, the risks of serious injury and illness do exist; and, 1. FOR MYSELF, SPOUSE, AND CHILD, I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASES or others, and assume full responsibility for my child’s participation; and, 2. I willingly agree to comply with the program’s stated and customary terms and conditions for participation. If I observe any unusual significant concern in my child’s readiness for participation and/or in the program itself, I will remove my child from the participation and bring such attention of the nearest official immediately; and, 3. I myself, my spouse, my child, and on behalf of my/our heirs, assigns, personal representatives and next of kin, HEREBY RELEASE AND HOLD HARMLESS Tennessee State Soccer Association (TSSA) and US Youth Soccer, their affiliated organizations or clubs and sponsors, their directors, officers, officials, agents, coaches, trainers, employees, volunteers, other participants, sponsoring agencies, sponsors, advertisers, and if applicable, owners and lessors of premises used to conduct the event (“Releasees”), WITH RESPECT TO ANY AND ALL INJURY, ILLNESS, DISABILITY, DEATH, or loss or damage to person or property incident to my child’s involvement or participation in these programs, WHETHER ARISING FROM THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE, to the fullest extent permitted by law. 4. I, for myself, my spouse, my child, and on behalf of my/our heirs, assigns, personal representatives and next of kin, HEREBY INDEMNIFY AND HOLD HARMLESS all the above Releasees from any and all liabilities incident to my involvement or participation in these programs, EVEN IF ARISING FROM THEIR NEGLIGENCE, to the fullest extent permitted by law.