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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