Head Injury/Concussion Report

This form is for the DC/CA/RS to report when a member returns to the field of play following a head injury or after suspicion of a concussion.

Person Submitting the Report

First Name

Last Name

Phone

Name

Club/Center

Region

Date of Incident

Was the injury sustained at a Pony Club activity?

When did the physician sign off on the Return to Play Form?

Did the physician understand what was being asked of him/her in signing the Return to Play Form?

When did the member/parent sign off on the Return to Play Form?

Did the member/parent understand what was being asked of him/her in signing the Return to Play Form?

How many mounted meetings/activities did the member miss?

Did the member participate in unmounted meetings, but not mounted meetings for a period of time?