Injury Notification Submission Form

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This form is for leagues within IL District 13 to submit when a player from their League incurs a serious injury. Completion and submission of this form notifies District 13 of the incident. Each league is still responsible for using the standard Little League International Accident Claim Form Process.

League Submitting Notification *

Name of League Personnel Submitting Form *

Email of League Personnel Submitting Form *

Location Where Injury Occurred *

Date Injury Occurred *

YYYY

Injured Player's Division of Play *

Injured Player's First and Last Name

Injured Player's Date of Birth *

YYYY

Injured Player's Parent First and Last Name *

Brief Description of Injury *

Brief Description of How Injury Occurred *

Has a Medical Claim Been Filed with Little League International? *

Yes

Submit

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