Nashua Youth Soccer League
Accident
/ Injury Report
Name of Injured Person: __________________________________________
Address: __________________________________________
Phone: __________________________________________
DOB:
_____________ Player ID: _____ -
___ - _____ (Social Security #)
Date & Time of Injury / Accident: ____________
Place: __________________
Type of Activity: Game:
________ Practice: ________
If game, Referee’s name:
__________________________________________
Weather: ________________ Field Conditions: ________________________
Describe how injury occurred:
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
Location of injury, brief description &
assessment of severity:
______________________________________________________________
______________________________________________________________
Was the player transported by ambulance? If so, name of service:
______________________________________________________________
Coach’s Signature: _________________ Date:
__________ Phone: __________
NOTE: The Coach must send a copy of this report to
the NYSL Chairman (P.O Box 247, Nashua, NH 03061-0247) & the New Hampshire
Soccer Association (1600 Candia Road, Manchester, NH 03109) within 48 hours of
the accident / injury. Any potential
insurance claims must be initiated with 30 days of the date of injury /
accident. Failure to adhere to these
deadlines may result in the loss of “excess” insurance coverage offered by the
New Hampshire Soccer Association.