Rowan’s Law Acknowledgment Form

The Ontario Government has enacted Rowan’s Law (Concussion Safety), 2018, S.O. 2018, c. 1(“Act”).Ontario Regulation 161/19,the Act requires all sport organizations as defined in the Regulation(“Sports Organization”), which includes the Belmont Minor Soccer Association(“BMSA”),to have a Concussion Code of Conduct. This Concussion Code of Conduct must require participants, as set out in the Act, to review the Ontario Government’s issued Concussion Awareness Resources on an annual basis. A participant is subject to a Concussion Code of Conduct for each Sports Organization a participant registers with.

Applicable age appropriate Concussion Awareness Resources are located at www.ontario.ca/concussions.The BMSA Concussion Code of Conduct (attached hereto as Appendix A) and the appropriate Concussion Awareness Resources (which can be located on our BMSA website) must be reviewed before you can register/participate in any soccer:

10 and Under Concussion Awareness Resource
11-14 Concussion Awareness Resource
15 and Over Concussion Awareness Resource 

Acknowledgement of Review

I,________________(first name) ___________________(last name)________________ 
(birthdate yyyy/mm/dd of athlete, Team Official or On-Ice Officials name) confirm that I have reviewed the BMSA Concussion Code of Conduct (Appendix A) and the appropriate Concussion Awareness Resources and commit to operating within the parameters of the BMSA Concussion Code of Conduct under the role which I have registered with the BMSA.

_____________________________________ _______________________
Signature Date

If the participant above is under the age of the 18, then the parent of that participant must also sign the Acknowledgement set out below.

I, _______________________________ (print name of parent if above signatory is under 18) confirm that I have reviewed the BMSA Concussion Code of Conduct and the appropriate Concussion Awareness Resources and commit that the signatory above and I will operate within the parameters of the BMSA Concussion Code of Conduct under the role which I have registered with the BMSA.

_____________________________________ _______________________
Signature Date

APPENDIX A

BMSA Concussion Code of Conduct 



I will help prevent concussions by my commitment to: 

Wearing the proper equipment for my sport and wearing it correctly;
Respecting the rules of my sport or activity; and
My commitment to fair play and respect for all* (respecting other athletes, coaches, team trainers and officials).

I will care for my and others health and safety by taking concussions seriously, and I understand that: 

A concussion is a brain injury that can have both short-and long-term effects;
Ablow to the head, face or neck, or a blow to the body that causes the brain to move around inside the skull may cause a concussion; and
A person does not need to lose consciousness to have had a concussion.

I will commit to:

Reporting any possible concussion received during participation in the game of soccer to a designated person;
Recognizing a concussion or possible concussion and the reporting to a designated person when an individual suspects that another individual may have sustained a concussion;  
Sharing any pertinent information regarding incidents of a removal from sport with the player’s school and other sport organization with which the player has registered;
Sharing any pertinent information regarding incidents of a concussion that have occurred outside of participation in the Belmont Minor Soccer Association to a designated person with your/individual’s team;
Complete Injury Report Forms in a timely manner and ensure they are submitted to the Belmont Minor Soccer Association;
Give commitment to providing opportunities before and after each training, practice and competition to enable participants to discuss potential issues related to concussions; and
Maintain an open dialogue with all athletes and participants (and parents/guardians in cases of minors) about their health and any signs and symptoms of concussion they may experience.




I will commit to respect the BMSA’s Removal and Return to Play Protocol by:

Understanding that if I have a suspected concussion, I will be removed from the sport and that I will not be able to return to training, practice or competition until I undergo a medical assessment by a medical doctor or nurse practitioner and have been medically cleared to return to training, practice or competition;
Understanding I will have to be medically cleared by a medical doctor or nurse practitioner before returning to training, practice or competition;
Respect the roles and responsibilities of all coaches and health care professionals in Return to Play protocol; and
Respond appropriately with Return to Play protocols if a participant is experiencing concussion related symptoms or if you suspect any participant has sustained a concussion.


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Willem Verhulst,
Mar 29, 2021, 5:26 PM
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