This form needs to be completed by a coach for any injuries that occur during the season. This applies to both football players and cheerleaders. Injuries should be reported within 3 days. Proper claim forms from league insurance should be made available to parents of injured players or cheerleaders. Complete all boxes before submitting. Print copy of this page before submitting. Upon submitting, this form will be mailed to the league President, Vice-President, and Secretary.
Athlete's Name:
Date of Birth (mm/dd/yy):
Team/Division:
Select One Football/Midget Football/Jr. Midget Football/Peewee Football/Jr. Peewee Football/Mitey Mite Cheerleading/Midget Cheerleading/Jr. Midget Cheerleading/Peewee Cheerleading/Jr. Peewee Cheerleading/Mitey Mites
Coach Submitting Report:
Coach's Email and Phone:
Head Coach's Name/Email/Phone:
Date/Time of Injury:
Type of Competition:
Location where injury occurred:
Type of Injury:
Was Parent Notified:
Select One Yes No
Was an Ambulance called:
Was any treatment rendered:
Name/Phone of person providing treatment:
Describe how injury occurred:
Describe how treatment was rendered:
List names and phone numbers of witnesses below.
Witness #1:
Witness #2:
Witness #3: