{1}
##LOC[OK]##
{1}
##LOC[OK]##
##LOC[Cancel]##
{1}
##LOC[OK]##
##LOC[Cancel]##
Our Board of Directors
About Us
Home
Coaching Corner
Game Schedules
Text Sign Up
Calendar
Downloads
Locations
Contact Us
Sponsors
Injury/Incident Report
Please complete this form regarding any injury/incident.
Name
Name of Player or Subject(s) of the Incident
Team Name
Name of Team Involved
Head Coach Name
Name of Head Coach
Program Type
select
Football
Cheerleading
Football or Cheerleading
Incident Type
select
Injury
Other Incident
Incident Type
Injury/Incident Date
RadDatePicker
RadDatePicker
Open the calendar popup.
Calendar
Title and navigation
Title and navigation
<<
<
October 2024
>
<<
October 2024
week
S
M
T
W
T
F
S
40
29
30
1
2
3
4
5
41
6
7
8
9
10
11
12
42
13
14
15
16
17
18
19
43
20
21
22
23
24
25
26
44
27
28
29
30
31
1
2
45
3
4
5
6
7
8
9
Actual Date of Injury/Incident
Incident/Injury Time
Time of injury/incident
Reported to Whom
select
Brian Baker
Justin Filzek
Taylor Peterman
Kaylajoy Yaek
Joe Adams
Mike Gojcaj
Who was the Injury/Incident Reported to?
Location
select
Anchor Bay High School
Port Huron Northern High School
Richmond High School
Memphis High School
Other
If injury/incident occured outside the locations listed, select other and detail it in your description
Witnesses
Who witnessed the incident/injury?
Setting
select
Practice
Game
Other
If the injury/incident occured outside of practice or a game, select other and detail it in your summary.
Injury Time Out
select
Yes
No
Injury was not game related
Was an injury time out called by the official?
Player Age Level
select
Junior Freshman
Freshman
Junior Varsity
Varsity
What age level?
Description
Brief Description of Injury/Incident
Reporting Party
Who is reporting this injury/incident?
Removed
select
Yes
No
N/A
In case of injury, was the athlete removed from practice or competition?
Police Contacted
select
Yes
No
N/A
Was law enforcement contacted?
Ambulance Called
select
Yes
No
N/A
Was EMS contacted?
Sent for Medical
select
Yes
No
N/A
Were the parent/guardian instructed to seek medical attention?
Parent Notification
select
Yes
No
N/A
Was the parent/guardian notified?
Medical Clearance
select
Yes
No
N/A
Were the parents/guardian instructed to provide medical clearance before the athlete can resume participation?
Concussion-Return
select
Yes
No
N/A
In the event of a concussion, was the return to play process explained to the parents/guardian?
Insurance Claim Form
select
Yes
No
N/A
Were the parents directed to the team website for insurance forms?
PSD Notification
select
Yes
No
Was Player Safety Director Mike Gojcaj notified?
Pres. Notification
select
Yes
No
Was Team President Brian Baker notified?
Additional Comments
Additional Comments
Date Submitted
RadDatePicker
RadDatePicker
Open the calendar popup.
Calendar
Title and navigation
Title and navigation
<<
<
October 2024
>
<<
October 2024
week
S
M
T
W
T
F
S
40
29
30
1
2
3
4
5
41
6
7
8
9
10
11
12
42
13
14
15
16
17
18
19
43
20
21
22
23
24
25
26
44
27
28
29
30
31
1
2
45
3
4
5
6
7
8
9
Report Submission Date
Required Fields