Age Grade Concussion Protocol Form

Please complete the form below and return asap to rugbysafe@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(Required)

Email Address(Required)

Position at Club/School/University/County(Required)

Email Address(Required)

Player's Full Name(Required)

Parent/Guardian Email Address(Required)

Player's Date of Birth(Required)

Date of Incident(Required)

Has the player's Parents or Guardian been informed?(Required)

Yes

Parent or Guardian Name(Required)

Does the parent/guardian give permission for information to be circulated(Required)

Yes

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

Yes

Please give a detailed overview of the incident(Required)

Player's Age Group(Required)

Player's Club(Required)

Lead Coach(Required)

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?(Required)

Yes

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

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