Elstead Sharks FC | Youth Football

Online Injury Form

To be completed by the session manager present at the time of the injury.

Date Injury Occurred

Time Injury Occurred

Event

Session Details

Session Manager Name

Injured Person's Details

INJURED PERSON'S DETAILS

First Name

Last Name

Date of Birth

Phone:

Address

Details

DETAILS OF ALL PLAYERS INVOLVED IN INCIDENT

Player 1 - Name

Player 1 - Phone Number

Player 2 - Name

Player 2 - Phone Number

Player 3 - Name

Player 3 - Phone Number

Witnesses

WITNESSES

Witness 1 - Name

Witness 1 - Phone Number

Witness 2 - Name

Witness 2 - Phone Number

Witness 3 - Name

Witness 3 - Phone Number

Incident Details

INCIDENT DETAILS

Describe Incident

Treatment

Treatment given by

Tick any of the below that apply

Loss of Consciousness

Person sent to Hospital

Ambulance Called

Declaration

I am the session manager named above and have provided information as accurately as possible.

Opt-In

I understand the information on this form maybe used to contact me and/or the players and witnesses listed.