Injury Report

Injury Report
Please submit within 72 hours if a rostered coach, assistant coach, or player gets injured and requires medical treatment.
Type of claimant*
Team name*
Name of injured person*

First NameMiddle NameLast Name
Gender*
Date of birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*

Area CodePhone Number
Event type where injury occurred*
Date of injury*

MonthDayYear
Date
Name of field/sports complex where injury occurred*
Describe the injury and how it occurred*
Location medical treatment was administered*
Should be Empty: