Players' Name: __________________________ Date of Injury: __/__/____

Town: _______________ Team: _______________ Coach: _______________

Location: Where specifically did the injury take place? _______________________

Home Field: _____ Away Field: _____ Other: _________________________

Explain: __________________________________________________________

Player Taken to Doctor or Hospital: Yes ___ No ___

Taken for Medical Attention by: Parents ___ Ambulance ___ Other _____________

Explain: __________________________________________________________

Were Parents Present: Yes ___ No ___

Were Parents Notified: Yes ___ No ___ Notified by Whom? _________________

Was a Local League Board Member Notified: Yes ___ No ___ Who? ____________

Write a brief description of the injury, what action was the player doing at the time of the injury.

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Did the Player have to stop practice or game activity? Yes ___ No ___

Did Player return to normal practice? Yes ___ No ___ If Yes when? ____________

If Player was unable to return to normal activity, we will need a doctor's note for player to return. Any Player that went to Doctor or Hospital must have a doctor's note to return.

Date of Injury: __/__/_____

Explain: __________________________________________________________________