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.