SFYBL - Injury Report
This form is to be filled out if a suspected/sustained injury that may result in a concussion occurs
It is mandatory to complete the form.
Any injured participant must immediately be seen and treated by a licensed health care professional for evaluation and clearance. Written documentation for release must be provided to SFYBL at execboard@sfybl.com before any injured individual will be allowed to participate in future events.

Please provide all information accurately.

Email address *
Date of injury *
The date the suspect/sustained injury occurred.
MM
/
DD
/
YYYY
Injured Party First and Last Name *
The name of the person who was injured.
Your answer
Location/Address
What was the physical address/location where the injury occurred?
*
Your answer
Name of Parent/Guardian for injured party *
First and Last Names
Your answer
Team Name - Division *
Select team from list
Phone number for Parent/Guardian *
415-xxx-xxxx
Your answer
Email for Parent/Guardian *
Your answer
Description of Incident *
Provide a brief account of how the suspected/sustained injury happened
Your answer
Treating Physician/Healthcare Provider *
Physician/Healthcare Provider's name and contact information (phone number/address)
Your answer
Restrictions / Estimated Return To Play Date *
Describe restrictions indicated by Healthcare Provider / Estimated return to play date (RTPD)
Your answer
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