Athlete’s Name: Athletic Trainer: Phone: Children’s Hospital Colorado Concussion Program 720-777-2806 Athlete’s Name: Athletic Trainer: Phone: Stage Activity Functional Exercise What Athlete Completed Date Completed Relative rest Easy walking such as a short walk around the neighborhood 1 Light aerobic activity 15-20 minutes, No resistance Examples: brisk walking, stationary cycling, 2 Non-contact sport-specific activity 30-45 minutes, No weight lifting, No head contact, Examples: skating in hockey, dribbling in soccer 3 Non-contact drills 1-2 hours, Progression to more complex drills, may start progressive resistance training Examples: blocking pads in football 4 Full-contact practice Following MEDICAL CLEARANCE, participate in normal training activities; full exertion, full pads and contact 5 Return to play Competitive game play and tournaments To proceed to next stage, athlete must remain symptom free for 24 hours. If symptoms reemerge, return to previous stage after 24 hours of rest.