Eastern New York Youth Soccer Association
Affiliated with E.N.Y.S.S.S.A. -- U.S.Y.S.A. -- U.S.S.F. -- F.I.F.A.

49 Front Street - Suite 2 - Rockville Centre, New York 11570
(516) 766-0849 - Fax (516) 678-7411

Mail or fax completed form to:

East Hudson Youth Soccer League
  407 Route 6
   Mahopac, N.Y. 10541
Fax: (845) 621-0114

Advanced Notification of Injury

Name:________________________________ Date/Time of Injury:___________

Address:__________________________________________________________

Phone:________________________________ Pass#:_____________________

Club:__________________________________ Team:_____________________

Date of Birth:______________________ S.S.#:__________________________

Type of Injury:_____________________________________________________

________________________________________________________________

_________________________________________________________________

_________________________________________________________________


Does the Injured Player Have Primary Insurance? YES___ NO___


Signed__________________________________________ Date _______________________
(Club Official) .

Please complete this form and mail or fax to the E.H.Y.S.L. at the above address.
Upon receipt of this form, a medical form will be sent to you.