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PBYFL INJURY INCIDENT FORM
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Organization :
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Andrews Aztecs
Odessa Oilers
Odessa Seahawks
Permian Basin Panthers
West Texas Cowboys
West Texas Jaguars
West Texas Cobras
Tall City Storm
Midland Chargers
West Texas Jr. Falcons
Odessa Youth Broncos
Odessa Bulldogs
Tackle, Flag, or Cheer?
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Tackle
Flag
Cheer
Age Group?
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Flag 4 & 5
Freshman 6 & 7
JV 8 & 9
Varsity 10 & 11
Player's Name:
Your answer
Parent(s) Name and Contact #:
Your answer
Parents Present at time of Injury?
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Yes
No
Date of Injury ?
MM
/
DD
/
YYYY
Time of Injury
Time
:
AM
PM
Location of Injury:
Your answer
First -Aid Rendered:
Your answer
Description of How Injury Occurred:
Your answer
Witness to Injury and Contact Info.
Your answer
Follow up: (Did player seek medical car, Ems called, home to rest?)
Your answer
By signing to this you agree the information above, you have provided is the truth.
Electronic Signature of Coach or AD
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