Injury Report

Injury Report

Panther City Rugby

This form is to be completed within 48 hours of an athlete's injury. Once complete, you will be able to access (download) the appropriate claim form(s) to recieve finanical assistance with medical expenses associated with you rugby injury.

Note that benefits are only available on acute injuries that occur during approved Panther City Rugby and/or USA Rugby activities. Engagement in rugby activities in the absence of a PCR approved coach are not considered approved activities.

If you have questions please contact an Panther City Rugby administrator.

Athlete's Full Name

First NameMiddle NameLast NameSuffix

Athlete's Sex

Athlete's Birth Date

MonthDayYear

Athlete's Age

Rugby Program

Athlete's School Team

Athlete's PCR Club Team

Community Activity

Coach's Name

Date of Injury

MonthDayYear

Event Type

When Did Injury Occur?

Injury Was Reported To Who?

Person's Name

Injured Area

Side of Body

Mechanism

Nature of Injury

Was the Athlete Treated Onsite

Type of Care Provided

The Athlete Was:

Was the Athlete Referred for Follow-Up Care

Where Was The Athlete Referred?

Please Provide Name of Facility / Person Athlete Was Referred To

Was Care Attained There

Name Of Person Completing This Form

First NameLast Name

Your Relation to Athlete

Your Mobile Phone Number

Format: (000) 000-0000.

Your E-mail