Injured Player Welfare Form

"*" indicates required fields

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*
Details of Person Recording the Injury*
Name
Role at Club
Phone Number
 
DD slash MM slash YYYY
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
e.g. parents took them the next day
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.

Northumberland Rugby Partners