Report A Youth Concussion

All concussions or head injuries which result in a player being removed from play and/or being placed on a Graduated Return to Sport programme (even where this is precautionary) must be reported to Hampshire RFU using the form below.

It is essential you wait for the ‘Thank you’ page to appear after submission to ensure the report is logged and automated emails triggered.

"*" indicates required fields

Phone

This field is for validation purposes and should be left unchanged.

Your Name*

Phone*

Email*

Position in club /school*

Has the Club RugbySafe Lead been informed?*

Yes

Player's Name*

Player's date of birth*

Player's age group*

Date of Incident/Head injury*

Location of Incident*

Summary of what happened including any presenting symptoms and attending First Aider's name (and any follow up)*

Player's school / college*

School / college email address*

Player's Rugby Club

Player's parent(s)' email address*

If you are not a Hampshire Club, fill in your Team Name here

Does the player attend any Girls U16 DPP or Girls U18 PDG?*

Yes

Does the player attend any Boys (Bath) PDG?*

Yes

Does player play for any other club?*

Yes

Please give name of other club