eNewsletter

A once-a-week email to keep you up to date so you don't miss any critical news or deadlines!

And we won't give you email address to any other organization, so your email address is safe with us.

Contact request successful. Thank you.

We will contact you shortly.

eNews Sign Up

Hide

Form I: Injury/Incident Report

This form is invalid if not submitted to CYM within thirty days of injury. The adult leader responsible for this event (coach of injured player,
youth minister, volunteer coordinator, etc.) must submit the form and confirm its receipt by CYM.

Name of Injured Participant*

Parish/School*

Grade*

Address*

City* State* Zip*

Date of Birth (mm/dd/yyyy)*

Phone Number*

Injury/Incident occurred:

Date of Injury*

Time*

Location*

Name of Activity*

Activity Sponsor: (Select One)* CYM Sports

Parish Event

Diocesan Event

Parish/School "In House" League/Camps

Name and title of person supervising event:*

Was this person a witness to the injury?* Yes

Nature of Injury (Please fully indicate what part of body was injured, etc.)* What happened? (Be specific in all details.)*

Was a doctor seen?* Yes

If yes, date (mm/dd/yyyy):*

Name of Doctor*

Phone Number of Doctor*

Your Name*

Your Email Address*

Your Work Phone*

Your Cell Phone*

About the information you provide

Please note that all information provided, including your name and contact information will never be shared with any third parties.

eNewsletter

Sign up

Contact request successful. Thank you.

Catholic Youth Ministries

Form I: Injury/Incident Report

Injury/Incident occurred:

About the information you provide