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Student Athlete Injury Form
Use this following an injury or illness at practice or competition.
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* Indicates required question
Your name and role:
*
Your answer
Student Name:
*
Your answer
Student Grade:
*
Your answer
Elmwood or Plum City?
*
Elmwood
Plum City
Student DOB (if known):
Your answer
Date of Incident:
*
MM
/
DD
/
YYYY
Time Incident Occurred:
*
Time
:
AM
PM
Location of Incident (be specific, E or PC, which gym/field, etc.):
*
Your answer
List a brief description of the incident:
*
Your answer
List the symptoms the athlete is experiencing:
*
Your answer
What treatment was provided? (ice, bandages, wrap/tape, medication, etc.)
*
Your answer
Was the athlete able to continue playing?
*
Yes
No
Was EMS/911needed?
*
Yes
No
How were parents notified? Parents must be notified following an injury at practice or competition.
*
Phone Call
Email
Text Message
Parents were present at the competition
Other:
Any other additional formation?
Your answer
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