Injury Report Form

Club Sport *

Date *

Month

Day

Year

Time of Injury *

Hour

:

Minute

am

pm

Name of Injured Player *

GWid of Injured Player

Gender of Injured Player *

Male

Female

Where did the injury occur? *

Body Part Injured *

Did the injury occur in a game or practice? *

Game

Practice

Please describe the cause of the injury *

What actions were taken at the scene? *

How did the injured player leave the area? *

Did the injured party go to the hospital? *

Yes

No

Name of Person Filing this Injury Report *

Email Address of Individual Filing this Injury Report *

Club Sports