This form is to be completed should an injury occur at a LYA sporting event. Please complete regardless of the severity of the injury. The form will be forward to the LYA Executive Board and Sports Commissioner for review.
Name of Person Injured:
If Minor, Name of Parent or Guardian:
Address:
Home Phone: Work Phone:
Coach's Name:
Date of Injury: Time of Injury:
Field or Location, where injury occurred:
Tryouts Scheduled Practice Scheduled Game Scheduled Tournament Other
Player Coach Assitant Coach Umpire Referee Scorekeeper Spectator Concession Stand Other
Baseball Basketball Field Hockey Lacrosse Soccer - Intramural Soccer - Travel Softball Wrestling
If Other: If Other:
Description of Injury:
Explanation of Injury (if player include position):
Was the injured person taken to hospital ? Yes No If Yes, Hospital Name:
How was the injured person taken to hospital ? Ambulance Private vehicle
Was the injured person seen by a physician ? Yes No
If Yes, Physicians Name: Phone:
Reported by: Phone:
