Age Grade Concussion Protocol Form

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Please complete the form below and return asap to 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.
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Has the player's Parents or Guardian been informed?*
Does the parent/guardian give permission for information to be circulated*
Has the Player/Guardian been notified that information will be kept on file and are happy that paperwork will be kept for reference.*
Is the player in County DPP, County Rugby, Newcastle Falcons Academy, ACE Scheme at Gosforth Academy, Newcastle Thunder, or any other Rugby League Team?*

Age Grade Playing Down Form | Regulation 15

"*" indicates required fields

Please reference Regulation 15.3 (playing up criteria) BEFORE completing this form.
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Criteria – Regulation 15.4.1

A | The player must be in a younger academic year at school/college than the player’s academic birth year;


B | The player’s safety may be compromised due to their small stature in comparison to other players in the same age grade or due to a developmental or behavioural issue.

Assessment & Safeguarding

Please confirm that a player assessment has been carried out based on the best practice guidelines notes in Regulation 15.4.2.
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For Under 13s and above, there must be written parental / guardian consent that they agree to the player playing down.
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The Club MUST agree to give the opposing team at least 48 hours notice of a player playing down.

Form Submission

This form MUST be signed off BEFORE the player plays down. Please do not allow the player to play down until signed off paperwork has been sent back to the club (copied to Club Chair of Age Grade and CSO) as this will invalidate insurance and create a safeguarding issue.

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