Club Sports Injury Report Form
This form should be submitted if a club sport member got injured during a practice, event, competition, demo, etc (if not done by a DAPER staff member on scene).  This includes suspected sprains, strains, concussions, fractures, etc.

This can be submitted by the injured person or by a fellow club member.
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Club Sport *
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Name of Injured Person *
First and last name
Email of Injured Person
Phone Number of Injured Person
ID Number of Injured Person
Affiliation of Injured Person
Where did the injury occur *
If on campus, state which facility.  If off campus, state which school/event/city you were at.
Did this injury occur at *
Date/Time of Injury *
List date and approx time
Part(s) of body injured *
How did the injury occur? *
Brief description of treatment/first aid/care given at time of injury
Was an ambulance called? *
If yes, refer to Club Sports Emergency Contact card to make appropriate phone call
If ambulance was called, was injured person transported to hospital?
If yes, refer to Club Sports Emergency Contact card to make appropriate phone call
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Has injured person gone to MIT Medical?
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Name of Person Submitting Form
(if different from injured person)
Email of Person Submitting Form
(if different from injured person)
Phone Number of Person Submitting Form
(if different from injured person)
Available Medical Resources On Campus
- Club Sport Information- http://clubsports.mit.edu/health-safety  Make an appointment (free of cost) to be evaluated by an athletic trainer.

- MIT Medical: http://medweb.mit.edu  Urgent Care is open every day from 8am-8pm.  This should not be used in lieu of emergency services, but it’s probably the quickest way to get connected to a medical professional in a non-emergency situation.  

- MIT Together: http://together.mit.edu  This site connects you to a variety of resources, both academically related and personally related.
Club Sport Emergency Card
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