Serious Injury Notification Form

Steve Lancaster (Head of Participation and Development, New Zealand Rugby)
021 528 737

Lisa Kingi-Bon (CEO of New Zealand Rugby Foundation)
021 212 7399

A head or spinal injury that results in the player being admitted to hospital
An injury or event (e.g. a heart attack) that results in the death of a player during match play or rugby training
An injury that is expected to result in some permanent disability (e.g. loss of use of a limb, loss of an eye)

Player Name

Date of Injury

Player's School/Club

Player's Team

Location of Player's Injury

Head

Neck

Other (Please Specify)

Describe What Happened

Please Indicate the Category of Serious injury

A head or spinal injury that results in the player being ADMITTED to hospital

An injury or event (e.g. a heart attack) that results in the death of a player during match play or rugby training

An injury that is expected to result in some PERMANENT disability (e.g. loss of use of a limb, loss of an eye)

If the injury does not meet any of the above criteria then you do not need to submit this form.

Your Name

Your Contact Number