Injured Player Welfare Form

"*" indicates required fields

Club*

Age Group*

Player Details. If player is under 18 record parent / guardian details below.*

Name

Email Address

Phone Number

Parent Details (if applicable)*

Name

Relation

Email Address

Phone Number

Player / Parent / Guardian Treatment Consent*

Yes

Address of Injured Player*

Details of Person Recording the Injury*

Name

Role at Club

Phone Number

Your Email Address*

Date of Injury*

Activity When Injury Occured*

What is the Injury?*

Factual Summary of Incident*

Factual Summary of Incident – how did the accident/injury happen, what was the cause? Please include as much information as possible. Did the injury occur during play/warm up/post-match? How did it happen? Any witnesses? Any foul play suspected? Assessment of Injury and what action was taken once the assessment had taken place Was player able to leave the pitch unaided? Was an ambulance called and if so, when – was it at the time of the incident or after?

Complete only if player attends hospital

Was the player taken to hospital either direct from the club or did they attend later?*

e.g. parents took them the next day

Was the player discharged from hospital or admitted overnight?*

If the player was kept in hospital overnight, please detail why*

If the player was discharged, is there a follow up appointment?*

Any other information that you feel is relevant

A copy of the form will then be sent on to Keith Atkinson – NRU Injured Player Welfare Officer so he may follow up with the person reporting the incident and then the player (or parents of the player, if U18).

Please Note: If the player was admitted to hospital and kept in overnight an additional RFU form will be required.

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