Injury Report Form

Injury Report Form
This Form is to be completed by the Head Coach or Team Manager with the parent/player, (with parent permission where needed) for record.

This Form will be sent to:

- Club Secretary

- Club Technical Director

- Club Junior or Youth Coordinator (when appropriate)

This Form may be required by the Insurance Company.

Members who are injured during the season or at the SKiLLS Training Program can apply for an Insurance Claim, to find out more please direct parent/player to Football Tasmania website.
Person Completing Form Name

First NameLast Name
Person Completing Form Email
example@example.com
Person Completing Form Mobile
example@example.com
1. Name of Person Injured/Incident

First NameLast Name
Parent Name of Person Injured/Incident (if under 18)

First NameLast Name
If person is associated to a team - name the team
2. Incident Details - when and where the incident occurred
Date of Injury/incident

MonthDayYear
Date
Time of Injury/incident

Hour Minutes

AM/PM Option
Address of Injury/incident
3. Brief Description of Type and Cause of Injury/incident
4. Person Rendering First Aid Treatment Details
Name

First NameLast Name
Phone Number
Details of any treatment/support:
6. Person Completing this Report
Name

First NameLast Name
Email
example@example.com
Phone
Sign
Date completing form

MonthDayYear
Date
Once submitted this form will go to Taroona Football Club Secretary secretary@taroonafc.org & technicaldirector@taroonafc.org
Should be Empty: