Injury Report Form
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Email *
Name of person filling in the form
記入者氏名
 *
Family name of player　受傷者の姓 *
Given name of player　受傷者の名前 *
Gender of player　性別 *
Age of player　年齢 *
Body weight (kg) 体重
Category of player　受傷者のカテゴリー *
Date of injury.　受傷日 *
MM
/
DD
/
YYYY
Time of injury　受傷時間 *
Weather　天気 *
Required
Place　受傷したグラウンド *
Please describe the circumstances of how the injury happened.
負傷時の状況
 *
 What you were doing and what happened.
何をしている時に、何が起きて、どうなったのか。
Body Part of injury　受傷部位 *
Required
Type of injury　受傷形態 *
Required
Mechanism of injury　受傷機転 *
Severity of Injury　重症度 *
Other things to contact
その他連絡事項
Registering information to make an insurance claim
保険金請求のための情報登録
If you wish to make a claim, please also complete the next section.
If the person registering this form is not the injured person making the claim or a family member of the injured person, the following sections can be left blank.

スポーツ安全保険へ保険金の請求を希望する方は次のセクションにもご記入をお願いします。
このフォームの登録者が保険金を請求する受傷者本人またはその家族でない場合は、次のセクションは無記入で結構です。
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