Accident/Injury Form

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This form is to be completed immediately following the occurrence of any injury that is severe enough to: warrant medical attention and/or treatment (i.e. first aid, emergency room, head bumps, nose bleeds, etc.) Keep all language impartial; present the information as facts only. Any concussion reported for follow up must be out of practices and games for 3 days from accident or injury.

Email *

Youth's First Name
*

Youth's Last Name
*

Select Program Youth is enrolled in:
*

Youth's Team Name:
*

Date of Accident/Injury:
*

Who was present (check all that apply):
*

Athletic Trainer

EMT

First Aid Volunteer

Required

List all staff present at time injury (coaches and trainers):
*

Please give a brief description of the incident:
*

Nature of Injury:
*

Did player return to practice/game:

Yes

Was additional medical attention required or advised:

Immediate Emergency Room/Doctor visit was required

Immediate Emergency Room/Doctor visit was recommended

Follow up with faimly doctor was recommended

No additional medical attention was recommended

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A copy of your responses will be emailed to the address you provided.

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