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21 APPENDIX- X- RETURN TO COMPETITION FORM RETURN TO COMPETITION This form is to be used after an athlete is removed from and not returned to competition after exhibiting concussion symptoms. MHSAA rules require written authorization from a physician (MD/DO) before an athlete may return to activity after exhibiting concussion symptoms that caused that athlete to be removed or the duration of a contest. In cases where an assigned MHSAA Tournament physician (MD/DO) is present, his or her decision to not allow a student to return to activity may not be overruled. Athlete:_______________________________________ School:_________________________________ Event/Sport:____________________________________ Date of Injury: ___________________________ REASON  FOR  ATHLETE’S  INCAPACITY ______________________________________________________________________________________ ______________________________________________________________________________________ PHYSICIAN’S  ACTION I have examined the named student-athlete following this episode and determined the following: Permission is granted for the athlete to return to activity (may not return to practice or competition on the same day as the injury). COMMENT: ________________________________________________________________ __________________________________________________________________________ _____________________________________________________ DATE:________________ PHYSICIAN’S  SIGNATURE  (Must  be  MD  or  DO) PHYSICIAN’S  NAME  (Printed): ________________________________________________ Copies to: Team Coach and Athletic Director Duplicate as Needed Michigan High School Athleti