Report an Injury – SWSA Soccer

Coaches, please use this form to submit injury requests to help the board keep track of injuries that have occurred.

Name of Athlete*
First Last
Date of Injury*
MM slash DD slash YYYY
Time of Injury*

: Hours

Minutes

AM/PM
Injury Occured During?*
Other Time of Injury
Was 911 Called?*
- Yes
- No
Did The Athlete Go To The Hospital?*
- Yes
- No
First Aider (Name)
First Last
Cause of Injury*
Type of Injury*
Anatomical Area Involved*
Extent of Injury*
First Aid Administered*
Other Treatment Administered
Referral Action
Name of Person Filling Out the Form*
First Last
Email of Person Filling Out the Form*
Enter Email Confirm Email
Phone Number of Person Filling Out the Form*

84109