Adult Concussion Protocol Form

"*" indicates required fields

Please complete the form below and return asap to titled Concussion Confidential. The County Office will then contact the club and other relevent groups eg, University or H.E. Coach, relevant County Representative Rugby Team Manager and Coach, within 48 hours. Please ensure you have informed the appropriate people within your club.
DD slash MM slash YYYY
DD slash MM slash YYYY
Does the player give permission for information to be circulated*
Player has been notified that information will be kept on file and is happy that paperwork will be kept for reference.*
Is the player in a County, Falcons Academy, University or Rugby League squad?*
If the player is playing both University and Club Rugby, please make sure you provide contact information for both lead coaches.

Quick Links

Northumberland Rugby Partners