VAR PRO | CCL PRO23 INFO REQUEST

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PLAYER INFORMATION

FIRST NAME *

LAST NAME *

GENDER *

Female

Male

BIRTH DATE *

YYYY

STREET ADDRESS *

CITY *

STATE *

ZIP CODE *

ARE YOU A VA RUSH ALUMNI *

Yes

COMMUNICATION INFORMATION

HOME PHONE NUMBER *

CELL PHONE NUMBER *

EMAIL ADDRESS *

PARENT CONTACT INFORMATION

PARENT 1-FIRST NAME *

PARENT 1-LAST NAME *

PARENT 1-EMAIL *

CONCUSSION INFORMATION

WHEN IN DOUBT, SIT OUT - IT IS BETTER TO MISS ONE GAME THAN THE WHOLE SEASON.

What is a Concussion?
A concussion is a type of traumatic brain injury that changes the way the brain normally works. A concussion is caused by a bump,blow. or jolt to the head or body that causes the head and brain to move quickly back and forth. Even a "ding" "getting your bell rung" or what seems to be a mild bump or blow to the head can be serious.

What are the signs and symptoms of concussion?
Signs and symptoms of concussion can show up right after the injury or may not appear or be noticed until days or weeks after the injury.

Headache or "pressure" in head
Nausea or vomiting
Balance problems or dizziness
Double or blurry vision
Sensitivity to light
Sensitivity to noise
Feeling sluggish, hazy, foggy, or groggy
Concentration or memory problems
Confusion
Just not "feeling right" or is "feeling down"

The Virginia Rush Concussion Policy is available on varush.com under Programs/Heath & Safety.
VA Rush requires all Advanced Players & Parent sign and return to the VA Rush Office the VA Rush Parent & Athlete Concussion Information Sheet. Download and Print VA Rush Parent & Athlete Concussion Information Sheet.

Parents are encouraged to complete the CDC Heads Up Online Concussion Course available at varush.com under Programs/Health&Safety/Concussion Resources.

I have read and understand the concussion information and requirements.

Required

IMPORTANT POLICY INFORMATION

* Read the following information and check each box to indicate your agreement.

I hereby release the Virginia Rush Soccer Club, Inc., Board of Directors, coaches, and other officials of the program from any responsibility for injury to my child suffered during practices or a game. In the event of such injury, I hereby give permission for my child to receive appropriate medical treatment. I agree to abide by the decisions and policies of the VRSC Board of Directors as in effect from time to time and authorize VRSC to release the information on this application to VYSA and USSF.

The Virginia Rush Soccer Club has my permission to photograph my child as a participant in Virginia Rush activities. I give my permission for the Virginia Rush to use such pictures in Virginia Rush publications, promotional materials, displays, and in various public media. I understand I will receive no compensation for the use of photographs.

Required

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