Create a Liability Alert Form

Please return this form to your chapter secretary with 72 hours after a game in which in the opinion of an on field official, there is a SERIOUS injury.

Please print using your browser's print function.
Send one to your chapter secretary and keep a copy for yourself. If you hit Submit a copy will be saved electronically.

Dennis Geisler - Sec/Treas.
24 Rondout Lane
Accord, NY 12404
FAX - 845-626-1370

Game Date:
Location:
Injured Player Name & Number:
Schools Playing in the Contest:
Level of Play:
Weather Conditions:
Field Condition:
Referee:
Umpire:
Head Linesman :
Line Judge :
Back Judge:
Description of What Occurred:
Date of Report:
Reporting Official E-mail:
Chapter:

	Please return this form to your chapter secretary with 72 hours after a game in which in the opinion of an on field official, there is a SERIOUS injury. Please print using your browser's print function. Send one to your chapter secretary and keep a copy for yourself. If you hit Submit a copy will be saved electronically. Dennis Geisler - Sec/Treas. 24 Rondout Lane Accord, NY 12404 FAX - 845-626-1370