When a Michigan athlete is removed from activity for concussion symptoms and not returned that day, MHSAA rules require unconditional written clearance from an MD, DO, PA or NP and consent from the student and parent before return. This form captures both, Section 1 for the medical examiner and Section 2 for the family.
An MD, DO, physician assistant or nurse practitioner signs Section 1, granting return to unrestricted activity, and prints their name. The student, and a parent or guardian if the student is under 18, sign Section 2.
Download the current version from the source each time; forms change without notice.
Return to Activity & Post-Concussion Consent Form
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The medical examiner must approve the student's return to unrestricted activity. MHSAA states it is not enough to approve the student to begin a return-to-activity progression, or to authorize return pending completion of one, so the signature should come after any progression is finished.
An MD, DO, physician assistant or nurse practitioner, who circles the credential next to the signature in Section 1 and prints their name. The student, and a parent or guardian for students under 18, then sign the Section 2 consent.
The school keeps it on file for seven years after the student's high school graduation and sends a copy to MHSAA by email or fax. The school also records the MHSAA head injury report ID in the school-use section.