Age Grade Concussion Protocol Form

"*" indicates required fields

Please complete the form below and return asap to concussions@northumberlandrfu.co.uk titled Concussion Confidential. The County Office will then contact the following if parent/guardian has agreed: Club contacts, School/ACE/College contact, County Representative Rugby Team Manager and Lead Coach, DPP Lead Coach, Falcons Academy Contacts (Rugby Union and/or League, as appropriate) within 48 hours. Parent/Guardian will be copied in on the e-mail sent. Please ensure you have informed the appropriate people within your club/school.

Name of person completing the form*

Email Address*

Position at Club/School/University/County*

Player's Full Name*

Parent/Guardian Email Address*

Player's Date of Birth*

Date of Incident*

Has the player's Parents or Guardian been informed?*

Yes

Parent or Guardian Name*

Does the parent/guardian give permission for information to be circulated*

Yes

Has the Player/Guardian been notified that information will be kept on file and are happy that paperwork will be kept for reference.*

Yes

Please give a detailed overview of the incident*

Player's Age Group*

Player's Club*

Lead Coach*

Player's School or College

Lead Coach

Is the player in County DPP, County Rugby, Newcastle Falcons Academy, ACE Scheme at Gosforth Academy, Newcastle Thunder, or any other Rugby League Team?*

Yes

If 'yes' please give details of the team the player is part of, coaches contact details and age group

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