{"id":4051,"date":"2026-03-01T20:58:52","date_gmt":"2026-03-02T01:58:52","guid":{"rendered":"https:\/\/i9development.com\/Dev6\/?page_id=4051"},"modified":"2026-04-14T11:40:22","modified_gmt":"2026-04-14T15:40:22","slug":"injury-report-form","status":"publish","type":"page","link":"https:\/\/i9development.com\/Dev6\/resources\/forms\/injury-report-form\/","title":{"rendered":"Injury Report"},"content":{"rendered":"\n<style type=\"text\/css\" data-created_by=\"avia_inline_auto\" id=\"style-css-av-mkqlbm5g-884f161c2bbdea3b383ae016f63dbd37\">\n.avia-section.av-mkqlbm5g-884f161c2bbdea3b383ae016f63dbd37{\nbackground-repeat:no-repeat;\nbackground-image:url(https:\/\/i9development.com\/Dev6\/wp-content\/uploads\/2026\/01\/NSA-banner-1.jpg);\nbackground-position:50% 50%;\nbackground-attachment:scroll;\n}\n.avia-section.av-mkqlbm5g-884f161c2bbdea3b383ae016f63dbd37 .av-section-color-overlay{\nopacity:0.7;\nbackground-color:#0a0a0a;\n}\n<\/style>\n<div id='av_section_1'  class='avia-section av-mkqlbm5g-884f161c2bbdea3b383ae016f63dbd37 alternate_color avia-section-default avia-no-border-styling  avia-builder-el-0  el_before_av_section  avia-builder-el-first  avia-full-stretch avia-bg-style-scroll av-section-color-overlay-active av-minimum-height av-minimum-height-40 av-height-percent  container_wrap fullsize'  data-section-bg-repeat='stretch' data-av_minimum_height_pc='40' data-av_min_height_opt='percent'><div class=\"av-section-color-overlay-wrap\"><div class=\"av-section-color-overlay\"><\/div><div class='container av-section-cont-open' ><main  role=\"main\" itemprop=\"mainContentOfPage\"  class='template-page content  av-content-full alpha units'><div class='post-entry post-entry-type-page post-entry-4051'><div class='entry-content-wrapper clearfix'>\n<div  class='flex_column av-5dvnz7-4b644b536cbb3dda04ef0cc960e0f0bd av_one_half  avia-builder-el-1  avia-builder-el-no-sibling  first flex_column_div  '     ><section  class='av_textblock_section av-mkqlbeor-9980dd58f14e778f3f83b3f99639468d '   itemscope=\"itemscope\" itemtype=\"https:\/\/schema.org\/CreativeWork\" ><div class='avia_textblock'  itemprop=\"text\" ><h1>Injury Reporting<\/h1>\n<\/div><\/section><\/div>\n\n<\/div><\/div><\/main><!-- close content main element --><\/div><\/div><\/div><div id='av_section_2'  class='avia-section av-3wa0dv-27c6ac381f95386ff38226b36427c994 main_color avia-section-default avia-no-border-styling  avia-builder-el-3  el_after_av_section  avia-builder-el-last  avia-bg-style-scroll container_wrap fullsize'  ><div class='container av-section-cont-open' ><div class='template-page content  av-content-full alpha units'><div class='post-entry post-entry-type-page post-entry-4051'><div class='entry-content-wrapper clearfix'>\n<div  class='flex_column av-30egnn-278fa0a5e26769dd4facaea1181aa2dd av_one_full  avia-builder-el-4  el_before_av_one_full  avia-builder-el-first  first flex_column_div  '     ><section  class='av_textblock_section av-mkqleg4f-c8baaa33b641d037319ef25aa5b57805 '   itemscope=\"itemscope\" itemtype=\"https:\/\/schema.org\/CreativeWork\" ><div class='avia_textblock'  itemprop=\"text\" ><p>Thank you for reporting your injury!<\/p>\n<p><span style=\"font-weight: 400;\">All registered NSA players, coaches, and officials are covered under the <\/span><a href=\"https:\/\/www.bcsoccer.net\/membership\/insurance\/\"><span style=\"font-weight: 400;\">BC Soccer Sport Accident Insurance Program<\/span><\/a><span style=\"font-weight: 400;\">.<\/span> <span style=\"font-weight: 400;\">for sanctioned activities.<\/span><\/p>\n<p>Now please fill out the attached Participant Accident Claims form.<\/p>\n<\/div><\/section><\/div><div  class='flex_column av-2batsj-e9885e02b16fcfdea08cfb179798aa11 av_one_full  avia-builder-el-6  el_after_av_one_full  el_before_av_textblock  first flex_column_div  column-top-margin'     ><section  class='av_textblock_section av-mkqlcfp2-4e67f3b9d9638a497ab81f7ead442608 '   itemscope=\"itemscope\" itemtype=\"https:\/\/schema.org\/CreativeWork\" ><div class='avia_textblock'  itemprop=\"text\" ><div class=\"frm_forms  with_frm_style frm_style_formidable-style\" id=\"frm_form_8_container\" data-token=\"9b6770f633612096ebed7d591645ae62\">\n<form enctype=\"multipart\/form-data\" method=\"post\" class=\"frm-show-form  frm_pro_form \" id=\"form_official-injury-report-form\" data-token=\"9b6770f633612096ebed7d591645ae62\">\n<div class=\"frm_form_fields \">\n<fieldset>\n<legend class=\"frm_screen_reader\">Injury Report<\/legend>\r\n\r\n<div class=\"frm_fields_container\">\n<input type=\"hidden\" name=\"frm_action\" value=\"create\" \/>\n<input type=\"hidden\" name=\"form_id\" value=\"8\" \/>\n<input type=\"hidden\" name=\"frm_hide_fields_8\" id=\"frm_hide_fields_8\" value=\"\" \/>\n<input type=\"hidden\" name=\"form_key\" value=\"official-injury-report-form\" \/>\n<input type=\"hidden\" name=\"item_meta[0]\" value=\"\" \/>\n<input type=\"hidden\" id=\"frm_submit_entry_8\" name=\"frm_submit_entry_8\" value=\"0fe38ce8e0\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/Dev6\/wp-json\/wp\/v2\/pages\/4051\" \/><div id=\"frm_field_73_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm12 frm_first\">\r\n\t<div  id=\"field_dyqbh_label\" class=\"frm_primary_label\">Name of person submitting the report\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/div>\r\n\t<fieldset aria-labelledby=\"field_dyqbh_label\">\n\t<legend class=\"frm_screen_reader frm_hidden\">\n\t\tName of person submitting the report\t<\/legend>\n\n\t<div  class=\"frm_combo_inputs_container\" id=\"frm_combo_inputs_container_73\" data-name-layout=\"first_last\">\n\t\t\t\t\t<div\n\t\t\t\tid=\"frm_field_73-first_container\"\n\t\t\t\tclass=\"frm_form_field form-field frm_form_subfield-first  frm6\"\n\t\t\t\tdata-sub-field-name=\"first\"\n\t\t\t>\n\t\t\t\t<label for=\"field_dyqbh_first\" class=\"frm_screen_reader frm_hidden\">\n\t\t\t\t\tFirst Name\t\t\t\t<\/label>\n\n\t\t\t\t<input  type=\"text\" id=\"field_dyqbh_first\" value=\"\" name=\"item_meta[73][first]\" autocomplete=\"given-name\" data-reqmsg=\"Name of person submitting the report cannot be blank.\" aria-required=\"true\" data-invmsg=\"Name of person submitting the report is invalid\" aria-invalid=\"false\"  \/><div class=\"frm_description\" id=\"frm_field_73_first_desc\">First Name<\/div>\t\t\t<\/div>\n\t\t\t\t\t\t<div\n\t\t\t\tid=\"frm_field_73-last_container\"\n\t\t\t\tclass=\"frm_form_field form-field frm_form_subfield-last  frm6\"\n\t\t\t\tdata-sub-field-name=\"last\"\n\t\t\t>\n\t\t\t\t<label for=\"field_dyqbh_last\" class=\"frm_screen_reader frm_hidden\">\n\t\t\t\t\tLast Name\t\t\t\t<\/label>\n\n\t\t\t\t<input  type=\"text\" id=\"field_dyqbh_last\" value=\"\" name=\"item_meta[73][last]\" autocomplete=\"family-name\" data-reqmsg=\"Name of person submitting the report cannot be blank.\" aria-required=\"true\" data-invmsg=\"Name of person submitting the report is invalid\" aria-invalid=\"false\"  \/><div class=\"frm_description\" id=\"frm_field_73_last_desc\">Last Name<\/div>\t\t\t<\/div>\n\t\t\t\t<\/div>\n<\/fieldset>\n\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_75_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_other_container\">\r\n\t<label for=\"field_rbctc\" id=\"field_rbctc_label\" class=\"frm_primary_label\">Role of person submitting the report\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t\t\t<select name=\"item_meta[75]\" id=\"field_rbctc\"  data-frmval=\"New Option\" data-reqmsg=\"Role of person submitting the report cannot be blank.\" aria-required=\"true\" data-invmsg=\"Role of person submitting the report is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"\"> <\/option><option  value=\"Parent\">Parent<\/option><option  value=\"Player\">Player<\/option><option  value=\"Team Manager\">Team Manager<\/option><option  value=\"Coach\">Coach<\/option><option  value=\"Other\" class=\"frm_other_trigger\" selected='selected'>Other<\/option>\t<\/select>\n\t<label for=\"field_rbctc-otext\" class=\"frm_screen_reader frm_hidden\">Role of person submitting the report<\/label><input type=\"text\" id=\"field_rbctc-otext\" class=\"frm_other_input\"  name=\"item_meta[other][75]\" value=\"New Option\" \/>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_76_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm6 frm_first\">\r\n\t<label for=\"field_5cf4\" id=\"field_5cf4_label\" class=\"frm_primary_label\">Date of incident\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t<input type=\"text\" id=\"field_5cf4\" name=\"item_meta[76]\" value=\"\"  maxlength=\"10\" data-reqmsg=\"Date of incident cannot be blank.\" aria-required=\"true\" data-invmsg=\"Date of incident is invalid\" class=\"frm_date\" aria-invalid=\"false\"  \/>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_77_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm6\">\r\n\t<div  id=\"field_u94et_label\" class=\"frm_primary_label\">Time of incident\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/div>\r\n\t<div class=\"frm_time_wrap\"><span dir=\"ltr\">\r\n<select aria-label=\"Time of incident ... hour\" name=\"item_meta[77][H]\" id=\"field_u94et_H\"  data-frmval=\"{&quot;H&quot;:&quot;&quot;,&quot;m&quot;:&quot;&quot;,&quot;A&quot;:&quot;&quot;,&quot;s&quot;:&quot;&quot;,&quot;ms&quot;:&quot;&quot;}\" data-reqmsg=\"Time of incident cannot be blank.\" aria-required=\"true\" data-invmsg=\"Time of incident is invalid\" class=\"auto_width frm_time_select\" aria-invalid=\"false\"  ><option value=\"\"  selected='selected'><\/option><option value=\"12\" >12<\/option><option value=\"1\" >1<\/option><option value=\"2\" >2<\/option><option value=\"3\" >3<\/option><option value=\"4\" >4<\/option><option value=\"5\" >5<\/option><option value=\"6\" >6<\/option><option value=\"7\" >7<\/option><option value=\"8\" >8<\/option><option value=\"9\" >9<\/option><option value=\"10\" >10<\/option><option value=\"11\" >11<\/option><\/select>\r\n<span class=\"frm_time_sep\" aria-hidden=\"true\">:<\/span>\r\n<select aria-label=\"Time of incident ... minute\" name=\"item_meta[77][m]\" id=\"field_u94et_m\"  data-frmval=\"{&quot;H&quot;:&quot;&quot;,&quot;m&quot;:&quot;&quot;,&quot;A&quot;:&quot;&quot;,&quot;s&quot;:&quot;&quot;,&quot;ms&quot;:&quot;&quot;}\" data-reqmsg=\"Time of incident cannot be blank.\" aria-required=\"true\" data-invmsg=\"Time of incident is invalid\" class=\"auto_width frm_time_select auto_width frm_time_select\" aria-invalid=\"false\"  ><option value=\"\"  selected='selected'><\/option><option value=\"00\" >00<\/option><option value=\"30\" >30<\/option><\/select>\r\n<\/span>\r\n<select aria-label=\"Time of incident\" name=\"item_meta[77][A]\" id=\"field_u94et_A\"  data-frmval=\"{&quot;H&quot;:&quot;&quot;,&quot;m&quot;:&quot;&quot;,&quot;A&quot;:&quot;&quot;,&quot;s&quot;:&quot;&quot;,&quot;ms&quot;:&quot;&quot;}\" data-reqmsg=\"Time of incident cannot be blank.\" aria-required=\"true\" data-invmsg=\"Time of incident is invalid\" class=\"auto_width frm_time_select auto_width frm_time_select auto_width frm_time_select\" aria-invalid=\"false\"  ><option value=\"AM\" >AM<\/option><option value=\"PM\" >PM<\/option><\/select>\r\n<\/div>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_78_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<label for=\"field_sfvuq\" id=\"field_sfvuq_label\" class=\"frm_primary_label\">Site\/facility of incident\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t<input  type=\"text\" id=\"field_sfvuq\" name=\"item_meta[78]\" value=\"\"  data-reqmsg=\"Site\/facility of incident cannot be blank.\" aria-required=\"true\" data-invmsg=\"Site\/facility of incident is invalid\" aria-invalid=\"false\"   \/>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_79_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<div  id=\"field_vq2ft_label\" class=\"frm_primary_label\">Name of injured person\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/div>\r\n\t<fieldset aria-labelledby=\"field_vq2ft_label\">\n\t<legend class=\"frm_screen_reader frm_hidden\">\n\t\tName of injured person\t<\/legend>\n\n\t<div  class=\"frm_combo_inputs_container\" id=\"frm_combo_inputs_container_79\" data-name-layout=\"first_last\">\n\t\t\t\t\t<div\n\t\t\t\tid=\"frm_field_79-first_container\"\n\t\t\t\tclass=\"frm_form_field form-field frm_form_subfield-first  frm6\"\n\t\t\t\tdata-sub-field-name=\"first\"\n\t\t\t>\n\t\t\t\t<label for=\"field_vq2ft_first\" class=\"frm_screen_reader frm_hidden\">\n\t\t\t\t\tFirst Name\t\t\t\t<\/label>\n\n\t\t\t\t<input  type=\"text\" id=\"field_vq2ft_first\" value=\"\" name=\"item_meta[79][first]\" data-reqmsg=\"Name of injured person cannot be blank.\" aria-required=\"true\" data-invmsg=\"Name of injured person is invalid\" aria-invalid=\"false\"  \/><div class=\"frm_description\" id=\"frm_field_79_first_desc\">First Name<\/div>\t\t\t<\/div>\n\t\t\t\t\t\t<div\n\t\t\t\tid=\"frm_field_79-last_container\"\n\t\t\t\tclass=\"frm_form_field form-field frm_form_subfield-last  frm6\"\n\t\t\t\tdata-sub-field-name=\"last\"\n\t\t\t>\n\t\t\t\t<label for=\"field_vq2ft_last\" class=\"frm_screen_reader frm_hidden\">\n\t\t\t\t\tLast Name\t\t\t\t<\/label>\n\n\t\t\t\t<input  type=\"text\" id=\"field_vq2ft_last\" value=\"\" name=\"item_meta[79][last]\" data-reqmsg=\"Name of injured person cannot be blank.\" aria-required=\"true\" data-invmsg=\"Name of injured person is invalid\" aria-invalid=\"false\"  \/><div class=\"frm_description\" id=\"frm_field_79_last_desc\">Last Name<\/div>\t\t\t<\/div>\n\t\t\t\t<\/div>\n<\/fieldset>\n\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_80_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<label for=\"field_8cou3\" id=\"field_8cou3_label\" class=\"frm_primary_label\">Role of injured person\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t\t\t<select name=\"item_meta[80]\" id=\"field_8cou3\"  data-frmval=\"New Option\" data-reqmsg=\"Role of injured person cannot be blank.\" aria-required=\"true\" data-invmsg=\"Role of injured person is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"\"> <\/option><option  value=\"Player\">Player<\/option><option  value=\"Coach\">Coach<\/option><option  value=\"Sectator\">Sectator<\/option><option  value=\"Volunteer\/Parent\">Volunteer\/Parent<\/option><option  value=\"Referee\">Referee<\/option>\t<\/select>\n\t\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_81_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm6 frm_first\">\r\n\t<label for=\"field_euedf\" id=\"field_euedf_label\" class=\"frm_primary_label\">Date of birth\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t<input type=\"text\" id=\"field_euedf\" name=\"item_meta[81]\" value=\"\"  maxlength=\"10\" data-reqmsg=\"Date of birth cannot be blank.\" aria-required=\"true\" data-invmsg=\"Date of birth is invalid\" class=\"frm_date\" aria-invalid=\"false\"  \/>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_82_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm6\">\r\n\t<label for=\"field_id47u\" id=\"field_id47u_label\" class=\"frm_primary_label\">Phone\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t<input type=\"tel\" id=\"field_id47u\" name=\"item_meta[82]\" value=\"\"  data-reqmsg=\"Phone cannot be blank.\" aria-required=\"true\" data-invmsg=\"Phone is invalid\" aria-invalid=\"false\" pattern=\"((\\+\\d{1,3}(-|.| )?\\(?\\d\\)?(-| |.)?\\d{1,5})|(\\(?\\d{2,6}\\)?))(-|.| )?(\\d{3,4})(-|.| )?(\\d{4})(( x| ext)\\d{1,5}){0,1}$\"  \/>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_84_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<div  id=\"field_vv75f_label\" class=\"frm_primary_label\">Address of injured person\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/div>\r\n\t<fieldset aria-labelledby=\"field_vv75f_label\">\n<legend class=\"frm_screen_reader frm_hidden\">\n\tAddress of injured person<\/legend>\n<div class=\"frm_combo_inputs_container\">\n<div id=\"frm_field_84-line1_container\" class=\"frm_form_field form-field \">\n\t<label for=\"field_vv75f_line1\" class=\"frm_screen_reader frm_hidden\">\n\t\tAddress of injured person\t<\/label>\n\t\t<input type=\"text\" id=\"field_vv75f_line1\" value=\"\" name=\"item_meta[84][line1]\"  data-reqmsg=\"Address of injured person cannot be blank.\" aria-required=\"true\" data-invmsg=\"Address of injured person is invalid\" aria-invalid=\"false\"   autocomplete=\"address-line1\" \/>\n\t<\/div>\n<div id=\"frm_field_84-line2_container\" class=\"frm_form_field form-field \">\n\t<label for=\"field_vv75f_line2\" class=\"frm_screen_reader frm_hidden\">\n\t\tAddress of injured person\t<\/label>\n\t\t<input type=\"text\" id=\"field_vv75f_line2\" value=\"\" name=\"item_meta[84][line2]\"  data-reqmsg=\"Address of injured person cannot be blank.\" aria-required=\"true\" data-invmsg=\"Address of injured person is invalid\" class=\"frm_optional\" aria-invalid=\"false\"   autocomplete=\"address-line2\" \/>\n\t<\/div>\n<div id=\"frm_field_84-city_container\" class=\"frm_form_field form-field frm_third frm_first\">\n\t<label for=\"field_vv75f_city\" class=\"frm_screen_reader frm_hidden\">\n\t\tCity\t<\/label>\n\t\t<input type=\"text\" id=\"field_vv75f_city\" value=\"\" name=\"item_meta[84][city]\"  data-reqmsg=\"Address of injured person cannot be blank.\" aria-required=\"true\" data-invmsg=\"Address of injured person is invalid\" aria-invalid=\"false\"   autocomplete=\"address-level2\" \/>\n\t<div class=\"frm_description\">City<\/div><\/div>\n<div id=\"frm_field_84-state_container\" class=\"frm_form_field form-field frm_third\">\n\t<label for=\"field_vv75f_state\" class=\"frm_screen_reader frm_hidden\">\n\t\tState\/Province\t<\/label>\n\t\t<input type=\"text\" id=\"field_vv75f_state\" value=\"\" name=\"item_meta[84][state]\"  data-reqmsg=\"Address of injured person cannot be blank.\" aria-required=\"true\" data-invmsg=\"Address of injured person is invalid\" aria-invalid=\"false\"   autocomplete=\"address-level1\" \/>\n\t<div class=\"frm_description\">State\/Province<\/div><\/div>\n<div id=\"frm_field_84-zip_container\" class=\"frm_form_field form-field frm_third\">\n\t<label for=\"field_vv75f_zip\" class=\"frm_screen_reader frm_hidden\">\n\t\tZip\/Postal\t<\/label>\n\t\t<input type=\"text\" id=\"field_vv75f_zip\" value=\"\" name=\"item_meta[84][zip]\"  data-reqmsg=\"Address of injured person cannot be blank.\" aria-required=\"true\" data-invmsg=\"Address of injured person is invalid\" aria-invalid=\"false\"   autocomplete=\"postal-code\" \/>\n\t<div class=\"frm_description\">Zip\/Postal<\/div><\/div>\n<div id=\"frm_field_84-country_container\" class=\"frm_form_field form-field \">\n\t<label for=\"field_vv75f_country\" class=\"frm_screen_reader frm_hidden\">\n\t\tCountry\t<\/label>\n\t\t\t<select name=\"item_meta[84][country]\" id=\"field_vv75f_country\"  data-reqmsg=\"Address of injured person cannot be blank.\" aria-required=\"true\" data-invmsg=\"Address of injured person is invalid\" aria-invalid=\"false\"   autocomplete=\"country-name\">\n\t\t\t<option value=\"\" class=\"\">\n\t\t\t\t \t\t\t<\/option>\n\t\t\t<option  value=\"Afghanistan\" data-code=\"AF\">Afghanistan<\/option><option  value=\"Aland Islands\" data-code=\"AX\">Aland Islands<\/option><option  value=\"Albania\" data-code=\"AL\">Albania<\/option><option  value=\"Algeria\" data-code=\"DZ\">Algeria<\/option><option  value=\"American Samoa\" data-code=\"AS\">American Samoa<\/option><option  value=\"Andorra\" data-code=\"AD\">Andorra<\/option><option  value=\"Angola\" data-code=\"AO\">Angola<\/option><option  value=\"Anguilla\" data-code=\"AI\">Anguilla<\/option><option  value=\"Antarctica\" data-code=\"AQ\">Antarctica<\/option><option  value=\"Antigua and Barbuda\" data-code=\"AG\">Antigua and Barbuda<\/option><option  value=\"Argentina\" data-code=\"AR\">Argentina<\/option><option  value=\"Armenia\" data-code=\"AM\">Armenia<\/option><option  value=\"Aruba\" data-code=\"AW\">Aruba<\/option><option  value=\"Australia\" data-code=\"AU\">Australia<\/option><option  value=\"Austria\" data-code=\"AT\">Austria<\/option><option  value=\"Azerbaijan\" data-code=\"AZ\">Azerbaijan<\/option><option  value=\"Bahamas\" data-code=\"BS\">Bahamas<\/option><option  value=\"Bahrain\" data-code=\"BH\">Bahrain<\/option><option  value=\"Bangladesh\" data-code=\"BD\">Bangladesh<\/option><option  value=\"Barbados\" data-code=\"BB\">Barbados<\/option><option  value=\"Belarus\" data-code=\"BY\">Belarus<\/option><option  value=\"Belgium\" data-code=\"BE\">Belgium<\/option><option  value=\"Belize\" data-code=\"BZ\">Belize<\/option><option  value=\"Benin\" data-code=\"BJ\">Benin<\/option><option  value=\"Bermuda\" data-code=\"BM\">Bermuda<\/option><option  value=\"Bhutan\" data-code=\"BT\">Bhutan<\/option><option  value=\"Bolivia\" data-code=\"BO\">Bolivia<\/option><option  value=\"Bonaire, Sint Eustatius and Saba\">Bonaire, Sint Eustatius and Saba<\/option><option  value=\"Bosnia and Herzegovina\" data-code=\"BA\">Bosnia and Herzegovina<\/option><option  value=\"Botswana\" data-code=\"BW\">Botswana<\/option><option  value=\"Bouvet Island\" data-code=\"BV\">Bouvet Island<\/option><option  value=\"Brazil\" data-code=\"BR\">Brazil<\/option><option  value=\"British Indian Ocean Territory\" data-code=\"IO\">British Indian Ocean Territory<\/option><option  value=\"Brunei\" data-code=\"BN\">Brunei<\/option><option  value=\"Bulgaria\" data-code=\"BG\">Bulgaria<\/option><option  value=\"Burkina Faso\" data-code=\"BF\">Burkina Faso<\/option><option  value=\"Burundi\" data-code=\"BI\">Burundi<\/option><option  value=\"C&ocirc;te d&#039;Ivoire\">C&ocirc;te d&#039;Ivoire<\/option><option  value=\"Cambodia\" data-code=\"KH\">Cambodia<\/option><option  value=\"Cameroon\" data-code=\"CM\">Cameroon<\/option><option  value=\"Canada\" data-code=\"CA\">Canada<\/option><option  value=\"Cape Verde\" data-code=\"CV\">Cape Verde<\/option><option  value=\"Cayman Islands\" data-code=\"KY\">Cayman Islands<\/option><option  value=\"Central African Republic\" data-code=\"CF\">Central African Republic<\/option><option  value=\"Chad\" data-code=\"TD\">Chad<\/option><option  value=\"Chile\" data-code=\"CL\">Chile<\/option><option  value=\"China\" data-code=\"CN\">China<\/option><option  value=\"Christmas Island\" data-code=\"CX\">Christmas Island<\/option><option  value=\"Cocos (Keeling) Islands\">Cocos (Keeling) Islands<\/option><option  value=\"Colombia\" data-code=\"CO\">Colombia<\/option><option  value=\"Comoros\" data-code=\"KM\">Comoros<\/option><option  value=\"Congo\">Congo<\/option><option  value=\"Cook Islands\" data-code=\"CK\">Cook Islands<\/option><option  value=\"Costa Rica\" data-code=\"CR\">Costa Rica<\/option><option  value=\"Croatia\" data-code=\"HR\">Croatia<\/option><option  value=\"Cuba\" data-code=\"CU\">Cuba<\/option><option  value=\"Curacao\" data-code=\"CW\">Curacao<\/option><option  value=\"Cyprus\" data-code=\"CY\">Cyprus<\/option><option  value=\"Czech Republic\" data-code=\"CZ\">Czech Republic<\/option><option  value=\"Denmark\" data-code=\"DK\">Denmark<\/option><option  value=\"Djibouti\" data-code=\"DJ\">Djibouti<\/option><option  value=\"Dominica\" data-code=\"DM\">Dominica<\/option><option  value=\"Dominican Republic\" data-code=\"DO\">Dominican Republic<\/option><option  value=\"East Timor\" data-code=\"TL\">East Timor<\/option><option  value=\"Ecuador\" data-code=\"EC\">Ecuador<\/option><option  value=\"Egypt\" data-code=\"EG\">Egypt<\/option><option  value=\"El Salvador\" data-code=\"SV\">El Salvador<\/option><option  value=\"Equatorial Guinea\" data-code=\"GQ\">Equatorial Guinea<\/option><option  value=\"Eritrea\" data-code=\"ER\">Eritrea<\/option><option  value=\"Estonia\" data-code=\"EE\">Estonia<\/option><option  value=\"Eswatini\">Eswatini<\/option><option  value=\"Ethiopia\" data-code=\"ET\">Ethiopia<\/option><option  value=\"Falkland Islands (Malvinas)\">Falkland Islands (Malvinas)<\/option><option  value=\"Faroe Islands\" data-code=\"FO\">Faroe Islands<\/option><option  value=\"Fiji\" data-code=\"FJ\">Fiji<\/option><option  value=\"Finland\" data-code=\"FI\">Finland<\/option><option  value=\"France\" data-code=\"FR\">France<\/option><option  value=\"French Guiana\" data-code=\"GF\">French Guiana<\/option><option  value=\"French Polynesia\" data-code=\"PF\">French Polynesia<\/option><option  value=\"French Southern Territories\" data-code=\"TF\">French Southern Territories<\/option><option  value=\"Gabon\" data-code=\"GA\">Gabon<\/option><option  value=\"Gambia\" data-code=\"GM\">Gambia<\/option><option  value=\"Georgia\" data-code=\"GE\">Georgia<\/option><option  value=\"Germany\" data-code=\"DE\">Germany<\/option><option  value=\"Ghana\" data-code=\"GH\">Ghana<\/option><option  value=\"Gibraltar\" data-code=\"GI\">Gibraltar<\/option><option  value=\"Greece\" data-code=\"GR\">Greece<\/option><option  value=\"Greenland\" data-code=\"GL\">Greenland<\/option><option  value=\"Grenada\" data-code=\"GD\">Grenada<\/option><option  value=\"Guadeloupe\" data-code=\"GP\">Guadeloupe<\/option><option  value=\"Guam\" data-code=\"GU\">Guam<\/option><option  value=\"Guatemala\" data-code=\"GT\">Guatemala<\/option><option  value=\"Guernsey\" data-code=\"GG\">Guernsey<\/option><option  value=\"Guinea\" data-code=\"GN\">Guinea<\/option><option  value=\"Guinea-Bissau\" data-code=\"GW\">Guinea-Bissau<\/option><option  value=\"Guyana\" data-code=\"GY\">Guyana<\/option><option  value=\"Haiti\" data-code=\"HT\">Haiti<\/option><option  value=\"Heard Island and McDonald Islands\" data-code=\"HM\">Heard Island and McDonald Islands<\/option><option  value=\"Holy See\">Holy See<\/option><option  value=\"Honduras\" data-code=\"HN\">Honduras<\/option><option  value=\"Hong Kong\" data-code=\"HK\">Hong Kong<\/option><option  value=\"Hungary\" data-code=\"HU\">Hungary<\/option><option  value=\"Iceland\" data-code=\"IS\">Iceland<\/option><option  value=\"India\" data-code=\"IN\">India<\/option><option  value=\"Indonesia\" data-code=\"ID\">Indonesia<\/option><option  value=\"Iran\" data-code=\"IR\">Iran<\/option><option  value=\"Iraq\" data-code=\"IQ\">Iraq<\/option><option  value=\"Ireland\" data-code=\"IE\">Ireland<\/option><option  value=\"Isle of Man\" data-code=\"IM\">Isle of Man<\/option><option  value=\"Israel\" data-code=\"IL\">Israel<\/option><option  value=\"Italy\" data-code=\"IT\">Italy<\/option><option  value=\"Jamaica\" data-code=\"JM\">Jamaica<\/option><option  value=\"Japan\" data-code=\"JP\">Japan<\/option><option  value=\"Jersey\" data-code=\"JE\">Jersey<\/option><option  value=\"Jordan\" data-code=\"JO\">Jordan<\/option><option  value=\"Kazakhstan\" data-code=\"KZ\">Kazakhstan<\/option><option  value=\"Kenya\" data-code=\"KE\">Kenya<\/option><option  value=\"Kiribati\" data-code=\"KI\">Kiribati<\/option><option  value=\"Kosovo\" data-code=\"XK\">Kosovo<\/option><option  value=\"Kuwait\" data-code=\"KW\">Kuwait<\/option><option  value=\"Kyrgyzstan\" data-code=\"KG\">Kyrgyzstan<\/option><option  value=\"Laos\" data-code=\"LA\">Laos<\/option><option  value=\"Latvia\" data-code=\"LV\">Latvia<\/option><option  value=\"Lebanon\" data-code=\"LB\">Lebanon<\/option><option  value=\"Lesotho\" data-code=\"LS\">Lesotho<\/option><option  value=\"Liberia\" data-code=\"LR\">Liberia<\/option><option  value=\"Libya\" data-code=\"LY\">Libya<\/option><option  value=\"Liechtenstein\" data-code=\"LI\">Liechtenstein<\/option><option  value=\"Lithuania\" data-code=\"LT\">Lithuania<\/option><option  value=\"Luxembourg\" data-code=\"LU\">Luxembourg<\/option><option  value=\"Macao\" data-code=\"MO\">Macao<\/option><option  value=\"Madagascar\" data-code=\"MG\">Madagascar<\/option><option  value=\"Malawi\" data-code=\"MW\">Malawi<\/option><option  value=\"Malaysia\" data-code=\"MY\">Malaysia<\/option><option  value=\"Maldives\" data-code=\"MV\">Maldives<\/option><option  value=\"Mali\" data-code=\"ML\">Mali<\/option><option  value=\"Malta\" data-code=\"MT\">Malta<\/option><option  value=\"Marshall Islands\" data-code=\"MH\">Marshall Islands<\/option><option  value=\"Martinique\" data-code=\"MQ\">Martinique<\/option><option  value=\"Mauritania\" data-code=\"MR\">Mauritania<\/option><option  value=\"Mauritius\" data-code=\"MU\">Mauritius<\/option><option  value=\"Mayotte\" data-code=\"YT\">Mayotte<\/option><option  value=\"Mexico\" data-code=\"MX\">Mexico<\/option><option  value=\"Micronesia\" data-code=\"FM\">Micronesia<\/option><option  value=\"Moldova\" data-code=\"MD\">Moldova<\/option><option  value=\"Monaco\" data-code=\"MC\">Monaco<\/option><option  value=\"Mongolia\" data-code=\"MN\">Mongolia<\/option><option  value=\"Montenegro\" data-code=\"ME\">Montenegro<\/option><option  value=\"Montserrat\" data-code=\"MS\">Montserrat<\/option><option  value=\"Morocco\" data-code=\"MA\">Morocco<\/option><option  value=\"Mozambique\" data-code=\"MZ\">Mozambique<\/option><option  value=\"Myanmar\" data-code=\"MM\">Myanmar<\/option><option  value=\"Namibia\" data-code=\"NA\">Namibia<\/option><option  value=\"Nauru\" data-code=\"NR\">Nauru<\/option><option  value=\"Nepal\" data-code=\"NP\">Nepal<\/option><option  value=\"Netherlands\" data-code=\"NL\">Netherlands<\/option><option  value=\"New Caledonia\" data-code=\"NC\">New Caledonia<\/option><option  value=\"New Zealand\" data-code=\"NZ\">New Zealand<\/option><option  value=\"Nicaragua\" data-code=\"NI\">Nicaragua<\/option><option  value=\"Niger\" data-code=\"NE\">Niger<\/option><option  value=\"Nigeria\" data-code=\"NG\">Nigeria<\/option><option  value=\"Niue\" data-code=\"NU\">Niue<\/option><option  value=\"Norfolk Island\" data-code=\"NF\">Norfolk Island<\/option><option  value=\"North Korea\" data-code=\"KP\">North Korea<\/option><option  value=\"North Macedonia\">North Macedonia<\/option><option  value=\"Northern Mariana Islands\" data-code=\"MP\">Northern Mariana Islands<\/option><option  value=\"Norway\" data-code=\"NO\">Norway<\/option><option  value=\"Oman\" data-code=\"OM\">Oman<\/option><option  value=\"Pakistan\" data-code=\"PK\">Pakistan<\/option><option  value=\"Palau\" data-code=\"PW\">Palau<\/option><option  value=\"Palestine\">Palestine<\/option><option  value=\"Panama\" data-code=\"PA\">Panama<\/option><option  value=\"Papua New Guinea\" data-code=\"PG\">Papua New Guinea<\/option><option  value=\"Paraguay\" data-code=\"PY\">Paraguay<\/option><option  value=\"Peru\" data-code=\"PE\">Peru<\/option><option  value=\"Philippines\" data-code=\"PH\">Philippines<\/option><option  value=\"Pitcairn\" data-code=\"PN\">Pitcairn<\/option><option  value=\"Poland\" data-code=\"PL\">Poland<\/option><option  value=\"Portugal\" data-code=\"PT\">Portugal<\/option><option  value=\"Puerto Rico\" data-code=\"PR\">Puerto Rico<\/option><option  value=\"Qatar\" data-code=\"QA\">Qatar<\/option><option  value=\"Reunion\" data-code=\"RE\">Reunion<\/option><option  value=\"Romania\" data-code=\"RO\">Romania<\/option><option  value=\"Russia\" data-code=\"RU\">Russia<\/option><option  value=\"Rwanda\" data-code=\"RW\">Rwanda<\/option><option  value=\"Saint Barthelemy\" data-code=\"BL\">Saint Barthelemy<\/option><option  value=\"Saint Helena, Ascension and Tristan da Cunha\">Saint Helena, Ascension and Tristan da Cunha<\/option><option  value=\"Saint Kitts and Nevis\" data-code=\"KN\">Saint Kitts and Nevis<\/option><option  value=\"Saint Lucia\" data-code=\"LC\">Saint Lucia<\/option><option  value=\"Saint Martin (French part)\">Saint Martin (French part)<\/option><option  value=\"Saint Pierre and Miquelon\" data-code=\"PM\">Saint Pierre and Miquelon<\/option><option  value=\"Saint Vincent and the Grenadines\" data-code=\"VC\">Saint Vincent and the Grenadines<\/option><option  value=\"Samoa\" data-code=\"WS\">Samoa<\/option><option  value=\"San Marino\" data-code=\"SM\">San Marino<\/option><option  value=\"Sao Tome and Principe\" data-code=\"ST\">Sao Tome and Principe<\/option><option  value=\"Saudi Arabia\" data-code=\"SA\">Saudi Arabia<\/option><option  value=\"Senegal\" data-code=\"SN\">Senegal<\/option><option  value=\"Serbia\" data-code=\"RS\">Serbia<\/option><option  value=\"Seychelles\" data-code=\"SC\">Seychelles<\/option><option  value=\"Sierra Leone\" data-code=\"SL\">Sierra Leone<\/option><option  value=\"Singapore\" data-code=\"SG\">Singapore<\/option><option  value=\"Sint Maarten (Dutch part)\">Sint Maarten (Dutch part)<\/option><option  value=\"Slovakia\" data-code=\"SK\">Slovakia<\/option><option  value=\"Slovenia\" data-code=\"SI\">Slovenia<\/option><option  value=\"Solomon Islands\" data-code=\"SB\">Solomon Islands<\/option><option  value=\"Somalia\" data-code=\"SO\">Somalia<\/option><option  value=\"South Africa\" data-code=\"ZA\">South Africa<\/option><option  value=\"South Georgia and the South Sandwich Islands\" data-code=\"GS\">South Georgia and the South Sandwich Islands<\/option><option  value=\"South Korea\" data-code=\"KR\">South Korea<\/option><option  value=\"South Sudan\" data-code=\"SS\">South Sudan<\/option><option  value=\"Spain\" data-code=\"ES\">Spain<\/option><option  value=\"Sri Lanka\" data-code=\"LK\">Sri Lanka<\/option><option  value=\"Sudan\" data-code=\"SD\">Sudan<\/option><option  value=\"Suriname\" data-code=\"SR\">Suriname<\/option><option  value=\"Svalbard and Jan Mayen\" data-code=\"SJ\">Svalbard and Jan Mayen<\/option><option  value=\"Sweden\" data-code=\"SE\">Sweden<\/option><option  value=\"Switzerland\" data-code=\"CH\">Switzerland<\/option><option  value=\"Syria\" data-code=\"SY\">Syria<\/option><option  value=\"Taiwan\" data-code=\"TW\">Taiwan<\/option><option  value=\"Tajikistan\" data-code=\"TJ\">Tajikistan<\/option><option  value=\"Tanzania\" data-code=\"TZ\">Tanzania<\/option><option  value=\"Thailand\" data-code=\"TH\">Thailand<\/option><option  value=\"Timor-Leste\">Timor-Leste<\/option><option  value=\"Togo\" data-code=\"TG\">Togo<\/option><option  value=\"Tokelau\" data-code=\"TK\">Tokelau<\/option><option  value=\"Tonga\" data-code=\"TO\">Tonga<\/option><option  value=\"Trinidad and Tobago\" data-code=\"TT\">Trinidad and Tobago<\/option><option  value=\"Tunisia\" data-code=\"TN\">Tunisia<\/option><option  value=\"Turkey\" data-code=\"TR\">Turkey<\/option><option  value=\"Turkmenistan\" data-code=\"TM\">Turkmenistan<\/option><option  value=\"Turks and Caicos Islands\" data-code=\"TC\">Turks and Caicos Islands<\/option><option  value=\"Tuvalu\" data-code=\"TV\">Tuvalu<\/option><option  value=\"Uganda\" data-code=\"UG\">Uganda<\/option><option  value=\"Ukraine\" data-code=\"UA\">Ukraine<\/option><option  value=\"United Arab Emirates\" data-code=\"AE\">United Arab Emirates<\/option><option  value=\"United Kingdom\" data-code=\"GB\">United Kingdom<\/option><option  value=\"United States\" data-code=\"US\">United States<\/option><option  value=\"United States Minor Outlying Islands\" data-code=\"UM\">United States Minor Outlying Islands<\/option><option  value=\"Uruguay\" data-code=\"UY\">Uruguay<\/option><option  value=\"Uzbekistan\" data-code=\"UZ\">Uzbekistan<\/option><option  value=\"Vanuatu\" data-code=\"VU\">Vanuatu<\/option><option  value=\"Vatican City\">Vatican City<\/option><option  value=\"Venezuela\" data-code=\"VE\">Venezuela<\/option><option  value=\"Vietnam\" data-code=\"VN\">Vietnam<\/option><option  value=\"Virgin Islands, British\">Virgin Islands, British<\/option><option  value=\"Virgin Islands, U.S.\">Virgin Islands, U.S.<\/option><option  value=\"Wallis and Futuna\" data-code=\"WF\">Wallis and Futuna<\/option><option  value=\"Western Sahara\" data-code=\"EH\">Western Sahara<\/option><option  value=\"Yemen\" data-code=\"YE\">Yemen<\/option><option  value=\"Zambia\" data-code=\"ZM\">Zambia<\/option><option  value=\"Zimbabwe\" data-code=\"ZW\">Zimbabwe<\/option>\t\t<\/select>\n\t<div class=\"frm_description\">Country<\/div><\/div>\n<\/div>\n<\/fieldset>\n\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_85_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<div  id=\"field_urk0e_label\" class=\"frm_primary_label\">Name of guardian or parent (if injured is a minor)\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/div>\r\n\t<fieldset aria-labelledby=\"field_urk0e_label\">\n\t<legend class=\"frm_screen_reader frm_hidden\">\n\t\tName of guardian or parent (if injured is a minor)\t<\/legend>\n\n\t<div  class=\"frm_combo_inputs_container\" id=\"frm_combo_inputs_container_85\" data-name-layout=\"first_last\">\n\t\t\t\t\t<div\n\t\t\t\tid=\"frm_field_85-first_container\"\n\t\t\t\tclass=\"frm_form_field form-field frm_form_subfield-first  frm6\"\n\t\t\t\tdata-sub-field-name=\"first\"\n\t\t\t>\n\t\t\t\t<label for=\"field_urk0e_first\" class=\"frm_screen_reader frm_hidden\">\n\t\t\t\t\tFirst Name\t\t\t\t<\/label>\n\n\t\t\t\t<input  type=\"text\" id=\"field_urk0e_first\" value=\"\" name=\"item_meta[85][first]\" data-reqmsg=\"Name of guardian or parent (if injured is a minor) cannot be blank.\" aria-required=\"true\" data-invmsg=\"Name of guardian or parent (if injured is a minor) is invalid\" aria-invalid=\"false\"  \/><div class=\"frm_description\" id=\"frm_field_85_first_desc\">First Name<\/div>\t\t\t<\/div>\n\t\t\t\t\t\t<div\n\t\t\t\tid=\"frm_field_85-last_container\"\n\t\t\t\tclass=\"frm_form_field form-field frm_form_subfield-last  frm6\"\n\t\t\t\tdata-sub-field-name=\"last\"\n\t\t\t>\n\t\t\t\t<label for=\"field_urk0e_last\" class=\"frm_screen_reader frm_hidden\">\n\t\t\t\t\tLast Name\t\t\t\t<\/label>\n\n\t\t\t\t<input  type=\"text\" id=\"field_urk0e_last\" value=\"\" name=\"item_meta[85][last]\" data-reqmsg=\"Name of guardian or parent (if injured is a minor) cannot be blank.\" aria-required=\"true\" data-invmsg=\"Name of guardian or parent (if injured is a minor) is invalid\" aria-invalid=\"false\"  \/><div class=\"frm_description\" id=\"frm_field_85_last_desc\">Last Name<\/div>\t\t\t<\/div>\n\t\t\t\t<\/div>\n<\/fieldset>\n\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_86_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<label for=\"field_s6rif\" id=\"field_s6rif_label\" class=\"frm_primary_label\">Was the parent\/guardian contacted about the incident?\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t\t\t<select name=\"item_meta[86]\" id=\"field_s6rif\"  data-frmval=\"New Option\" data-reqmsg=\"Was the parent\/guardian contacted about the incident? cannot be blank.\" aria-required=\"true\" data-invmsg=\"Was the parent\/guardian contacted about the incident? is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"\"> <\/option><option  value=\"Yes\">Yes<\/option><option  value=\"No\">No<\/option>\t<\/select>\n\t\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_87_container\" class=\"frm_form_field form-field  frm_top_container frm6 frm_first\">\r\n\t<div  id=\"field_gp9r2_label\" class=\"frm_primary_label\">Name of witness\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n\t<\/div>\r\n\t<fieldset aria-labelledby=\"field_gp9r2_label\">\n\t<legend class=\"frm_screen_reader frm_hidden\">\n\t\tName of witness\t<\/legend>\n\n\t<div  class=\"frm_combo_inputs_container\" id=\"frm_combo_inputs_container_87\" data-name-layout=\"first_last\">\n\t\t\t\t\t<div\n\t\t\t\tid=\"frm_field_87-first_container\"\n\t\t\t\tclass=\"frm_form_field form-field frm_form_subfield-first  frm6\"\n\t\t\t\tdata-sub-field-name=\"first\"\n\t\t\t>\n\t\t\t\t<label for=\"field_gp9r2_first\" class=\"frm_screen_reader frm_hidden\">\n\t\t\t\t\tFirst Name\t\t\t\t<\/label>\n\n\t\t\t\t<input  type=\"text\" id=\"field_gp9r2_first\" value=\"\" name=\"item_meta[87][first]\" data-invmsg=\"Name of witness is invalid\" aria-invalid=\"false\"  \/><div class=\"frm_description\" id=\"frm_field_87_first_desc\">First Name<\/div>\t\t\t<\/div>\n\t\t\t\t\t\t<div\n\t\t\t\tid=\"frm_field_87-last_container\"\n\t\t\t\tclass=\"frm_form_field form-field frm_form_subfield-last  frm6\"\n\t\t\t\tdata-sub-field-name=\"last\"\n\t\t\t>\n\t\t\t\t<label for=\"field_gp9r2_last\" class=\"frm_screen_reader frm_hidden\">\n\t\t\t\t\tLast Name\t\t\t\t<\/label>\n\n\t\t\t\t<input  type=\"text\" id=\"field_gp9r2_last\" value=\"\" name=\"item_meta[87][last]\" data-invmsg=\"Name of witness is invalid\" aria-invalid=\"false\"  \/><div class=\"frm_description\" id=\"frm_field_87_last_desc\">Last Name<\/div>\t\t\t<\/div>\n\t\t\t\t<\/div>\n<\/fieldset>\n\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_88_container\" class=\"frm_form_field form-field  frm_top_container frm6\">\r\n\t<label for=\"field_yrvgx\" id=\"field_yrvgx_label\" class=\"frm_primary_label\">Phone\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n\t<\/label>\r\n\t<input type=\"tel\" id=\"field_yrvgx\" name=\"item_meta[88]\" value=\"\"  data-invmsg=\"Phone is invalid\" aria-invalid=\"false\" pattern=\"((\\+\\d{1,3}(-|.| )?\\(?\\d\\)?(-| |.)?\\d{1,5})|(\\(?\\d{2,6}\\)?))(-|.| )?(\\d{3,4})(-|.| )?(\\d{4})(( x| ext)\\d{1,5}){0,1}$\"  \/>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_89_container\" class=\"frm_form_field form-field  frm_top_container frm6 frm_first\">\r\n\t<div  id=\"field_w9ybj_label\" class=\"frm_primary_label\">Name of witness\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n\t<\/div>\r\n\t<fieldset aria-labelledby=\"field_w9ybj_label\">\n\t<legend class=\"frm_screen_reader frm_hidden\">\n\t\tName of witness\t<\/legend>\n\n\t<div  class=\"frm_combo_inputs_container\" id=\"frm_combo_inputs_container_89\" data-name-layout=\"first_last\">\n\t\t\t\t\t<div\n\t\t\t\tid=\"frm_field_89-first_container\"\n\t\t\t\tclass=\"frm_form_field form-field frm_form_subfield-first  frm6\"\n\t\t\t\tdata-sub-field-name=\"first\"\n\t\t\t>\n\t\t\t\t<label for=\"field_w9ybj_first\" class=\"frm_screen_reader frm_hidden\">\n\t\t\t\t\tFirst Name\t\t\t\t<\/label>\n\n\t\t\t\t<input  type=\"text\" id=\"field_w9ybj_first\" value=\"\" name=\"item_meta[89][first]\" data-invmsg=\"Name of witness is invalid\" aria-invalid=\"false\"  \/><div class=\"frm_description\" id=\"frm_field_89_first_desc\">First Name<\/div>\t\t\t<\/div>\n\t\t\t\t\t\t<div\n\t\t\t\tid=\"frm_field_89-last_container\"\n\t\t\t\tclass=\"frm_form_field form-field frm_form_subfield-last  frm6\"\n\t\t\t\tdata-sub-field-name=\"last\"\n\t\t\t>\n\t\t\t\t<label for=\"field_w9ybj_last\" class=\"frm_screen_reader frm_hidden\">\n\t\t\t\t\tLast Name\t\t\t\t<\/label>\n\n\t\t\t\t<input  type=\"text\" id=\"field_w9ybj_last\" value=\"\" name=\"item_meta[89][last]\" data-invmsg=\"Name of witness is invalid\" aria-invalid=\"false\"  \/><div class=\"frm_description\" id=\"frm_field_89_last_desc\">Last Name<\/div>\t\t\t<\/div>\n\t\t\t\t<\/div>\n<\/fieldset>\n\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_90_container\" class=\"frm_form_field form-field  frm_top_container frm6\">\r\n\t<label for=\"field_ew0ev\" id=\"field_ew0ev_label\" class=\"frm_primary_label\">Phone\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n\t<\/label>\r\n\t<input type=\"tel\" id=\"field_ew0ev\" name=\"item_meta[90]\" value=\"\"  data-invmsg=\"Phone is invalid\" aria-invalid=\"false\" pattern=\"((\\+\\d{1,3}(-|.| )?\\(?\\d\\)?(-| |.)?\\d{1,5})|(\\(?\\d{2,6}\\)?))(-|.| )?(\\d{3,4})(-|.| )?(\\d{4})(( x| ext)\\d{1,5}){0,1}$\"  \/>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_91_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<label for=\"field_ljus8\" id=\"field_ljus8_label\" class=\"frm_primary_label\">Describe the incident and how it occurred: \r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t<textarea name=\"item_meta[91]\" id=\"field_ljus8\" rows=\"5\"  data-reqmsg=\"Describe the incident and how it occurred:  cannot be blank.\" aria-required=\"true\" data-invmsg=\"Describe the incident and how it occurred:  is invalid\" aria-invalid=\"false\"  ><\/textarea>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_92_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<label for=\"field_w4ul5\" id=\"field_w4ul5_label\" class=\"frm_primary_label\">Was any rule violated which contributed to the injury?\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t\t\t<select name=\"item_meta[92]\" id=\"field_w4ul5\"  data-frmval=\"New Option\" data-reqmsg=\"Was any rule violated which contributed to the injury? cannot be blank.\" aria-required=\"true\" data-invmsg=\"Was any rule violated which contributed to the injury? is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"\"> <\/option><option  value=\"Yes\">Yes<\/option><option  value=\"No\">No<\/option>\t<\/select>\n\t\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_93_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<label for=\"field_cd46h\" id=\"field_cd46h_label\" class=\"frm_primary_label\">Explain\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t<input  type=\"text\" id=\"field_cd46h\" name=\"item_meta[93]\" value=\"\"  data-reqmsg=\"Explain cannot be blank.\" aria-required=\"true\" data-invmsg=\"Explain is invalid\" aria-invalid=\"false\"   \/>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_94_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<label for=\"field_u33hw\" id=\"field_u33hw_label\" class=\"frm_primary_label\">Describe the type of injury and the part of the body injured: \r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t<textarea name=\"item_meta[94]\" id=\"field_u33hw\" rows=\"5\"  data-reqmsg=\"Describe the type of injury and the part of the body injured:  cannot be blank.\" aria-required=\"true\" data-invmsg=\"Describe the type of injury and the part of the body injured:  is invalid\" aria-invalid=\"false\"  ><\/textarea>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_95_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<label for=\"field_fj98n\" id=\"field_fj98n_label\" class=\"frm_primary_label\">Describe the treatment or other actions taken: \r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t<textarea name=\"item_meta[95]\" id=\"field_fj98n\" rows=\"5\"  data-reqmsg=\"Describe the treatment or other actions taken:  cannot be blank.\" aria-required=\"true\" data-invmsg=\"Describe the treatment or other actions taken:  is invalid\" aria-invalid=\"false\"  ><\/textarea>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_96_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<div  id=\"field_42kmc_label\" class=\"frm_primary_label\">Name of person giving the treatment: \r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/div>\r\n\t<fieldset aria-labelledby=\"field_42kmc_label\">\n\t<legend class=\"frm_screen_reader frm_hidden\">\n\t\tName of person giving the treatment: \t<\/legend>\n\n\t<div  class=\"frm_combo_inputs_container\" id=\"frm_combo_inputs_container_96\" data-name-layout=\"first_last\">\n\t\t\t\t\t<div\n\t\t\t\tid=\"frm_field_96-first_container\"\n\t\t\t\tclass=\"frm_form_field form-field frm_form_subfield-first  frm6\"\n\t\t\t\tdata-sub-field-name=\"first\"\n\t\t\t>\n\t\t\t\t<label for=\"field_42kmc_first\" class=\"frm_screen_reader frm_hidden\">\n\t\t\t\t\tFirst Name\t\t\t\t<\/label>\n\n\t\t\t\t<input  type=\"text\" id=\"field_42kmc_first\" value=\"\" name=\"item_meta[96][first]\" data-reqmsg=\"Name of person giving the treatment:  cannot be blank.\" aria-required=\"true\" data-invmsg=\"Name of person giving the treatment:  is invalid\" aria-invalid=\"false\"  \/><div class=\"frm_description\" id=\"frm_field_96_first_desc\">First Name<\/div>\t\t\t<\/div>\n\t\t\t\t\t\t<div\n\t\t\t\tid=\"frm_field_96-last_container\"\n\t\t\t\tclass=\"frm_form_field form-field frm_form_subfield-last  frm6\"\n\t\t\t\tdata-sub-field-name=\"last\"\n\t\t\t>\n\t\t\t\t<label for=\"field_42kmc_last\" class=\"frm_screen_reader frm_hidden\">\n\t\t\t\t\tLast Name\t\t\t\t<\/label>\n\n\t\t\t\t<input  type=\"text\" id=\"field_42kmc_last\" value=\"\" name=\"item_meta[96][last]\" data-reqmsg=\"Name of person giving the treatment:  cannot be blank.\" aria-required=\"true\" data-invmsg=\"Name of person giving the treatment:  is invalid\" aria-invalid=\"false\"  \/><div class=\"frm_description\" id=\"frm_field_96_last_desc\">Last Name<\/div>\t\t\t<\/div>\n\t\t\t\t<\/div>\n<\/fieldset>\n\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_97_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<label for=\"field_u1tg2\" id=\"field_u1tg2_label\" class=\"frm_primary_label\">Were emergency medical services contacted? \r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t\t\t<select name=\"item_meta[97][]\" id=\"field_u1tg2\"  multiple=\"multiple\"  data-frmval=\"New Option\" data-reqmsg=\"Were emergency medical services contacted?  cannot be blank.\" aria-required=\"true\" data-invmsg=\"Were emergency medical services contacted?  is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"\"> <\/option><option  value=\"Yes\">Yes<\/option><option  value=\"No\">No<\/option>\t<\/select>\n\t\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_98_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<label for=\"field_48bid\" id=\"field_48bid_label\" class=\"frm_primary_label\">Was the injured person transported to a medical facility? \r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t\t\t<select name=\"item_meta[98]\" id=\"field_48bid\"  data-frmval=\"New Option\" data-reqmsg=\"Was the injured person transported to a medical facility?  cannot be blank.\" aria-required=\"true\" data-invmsg=\"Was the injured person transported to a medical facility?  is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"\"> <\/option><option  value=\"Yes\">Yes<\/option><option  value=\"No\">No<\/option>\t<\/select>\n\t\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_99_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm6 frm_first\">\r\n\t<label for=\"field_rbv4w\" id=\"field_rbv4w_label\" class=\"frm_primary_label\">Signature of Coach\/Official:\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t<div class=\"sigPad\" id='sigPad99' style=\"max-width:400px;\">\n\t<div class=\"sig sigWrapper\" style=\"height:150px;border-color:#D0D5DD;--bg-color:#ffffff;--active:#4199FD;--inactive:#EAECF0;--active-text:#ffffff;--inactive-text:#1D2939;--button-margin:22px;--button-size:20px;--button-padding:10px;--button-side-margin:22px;--icon:20px\">\n\n\t\t<ul class=\"sigNav\">\n\t\t\t\t<li class=\"drawIt\">\n\t\t\t\t\t<a href=\"#\" class=\"frm-active-sig-type\" title=\"Draw It\" aria-label=\"Draw It\">\n\t\t\t\t\t\t<svg  viewBox=\"0 0 22 20\" class=\"frmsvg\">\n\t<title>signature<\/title>\n\t<path d=\"M19.7 2.2A3.5 3.5 0 0 0 14 1.1L1.7 13.4a1 1 0 0 0-.3.4l-1.3 5a.9.9 0 0 0 0 .5 1 1 0 0 0 1 .6l5-1.3c.2 0 .4-.1.5-.3L18.9 6a3.5 3.5 0 0 0 .7-3.8zm-6.8 2.6L15.2 7l-8.6 8.7-2.4-2.4zm-10.7 13l1-3.3L5.4 17zM18 4.2l-.4.5L16.3 6 14 3.7l1.3-1.3A1.7 1.7 0 0 1 18 3.6l-.1.6zM9 17.9h11v1H9v-1z\"><\/path>\n\n<\/svg>\t\t\t\t\t<\/a>\n\t\t\t\t<\/li>\n\t\t\t\t<li class=\"typeIt\">\n\t\t\t\t\t<a href=\"#\" class=\"\" title=\"Type It\" aria-label=\"Type It\">\n\t\t\t\t\t\t<svg  viewBox=\"0 0 22 20\" class=\"frmsvg\">\n\t<title>keyboard<\/title>\n\t<path d=\"M20.6 2.5H2c-1 0-1.9.8-1.9 1.9v11.2c0 1 .8 1.9 1.9 1.9h18.7c1 0 1.9-.8 1.9-1.9V4.4c0-1-.8-1.9-1.9-1.9zm.3 13.1c0 .2-.1.3-.3.3H2a.3.3 0 0 1-.3-.3V4.4c0-.2.1-.3.3-.3h18.7c.2 0 .3.1.3.3v11.2zm-14.3-5V9.4c0-.3-.2-.5-.4-.5H5c-.3 0-.5.2-.5.5v1c0 .3.2.5.5.5h1c.3 0 .5-.2.5-.5zm3.8 0V9.4c0-.3-.2-.5-.5-.5H9c-.3 0-.5.2-.5.5v1c0 .3.2.5.4.5H10c.3 0 .5-.2.5-.5zm3.7 0V9.4c0-.3-.2-.5-.4-.5h-1.1c-.3 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aria-required=\"true\" class=\"auto_width\" aria-invalid=\"false\"   \/>\n\t\t<\/div>\n\n\t\t<canvas class=\"pad\" data-fieldid=\"99\" data-fieldname=\"item_meta[99]\" width=\"396\" height=\"150\"><\/canvas>\n\t\t<div class=\"clearButton\"><a href=\"#clear\">Clear<\/a><\/div>\n\n\t\t<input type=\"hidden\" name=\"item_meta[99][output]\" class=\"output\" value=\"\" \/>\n\t<\/div>\n<\/div>\n\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_45_container\" class=\"frm_form_field form-field  frm6\">\r\n\t<div class=\"frm_submit frm_flex\">\r\n<button class=\"frm_button_submit frm_final_submit\" type=\"submit\"  >Submit<\/button>\r\n\r\n\r\n\r\n<\/div>\r\n<\/div>\n\t<input type=\"hidden\" name=\"item_key\" value=\"\" \/>\n\t\t\t<div id=\"frm_field_185_container\">\n\t\t\t<label for=\"field_qx2pg\" >\n\t\t\t\tIf you are human, leave this field blank.\t\t\t<\/label>\n\t\t\t<input  id=\"field_qx2pg\" type=\"text\" class=\"frm_form_field form-field frm_verify\" name=\"item_meta[185]\" value=\"\"  \/>\n\t\t<\/div>\n\t\t<input name=\"frm_state\" type=\"hidden\" value=\"Md5044cNhdGgzt29RZhxKdZVn4l4YgFjXZ9vSwmsKsHFNSqWbTX7t2N3YIpuRjuG\" \/><\/div>\n<\/fieldset>\n<\/div>\n\n<\/form>\n<\/div>\n\n<\/div><\/section><\/div><section  class='av_textblock_section av-mkqlcqd8-b45a0d38ae8d64f84710ddd9f17b674d '   itemscope=\"itemscope\" itemtype=\"https:\/\/schema.org\/CreativeWork\" ><div class='avia_textblock'  itemprop=\"text\" ><\/div><\/section>\n\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":10,"featured_media":0,"parent":3550,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_acf_changed":false,"footnotes":""},"class_list":["post-4051","page","type-page","status-publish","hentry"],"acf":[],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.5 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>NSA | Injury Report<\/title>\n<meta name=\"robots\" content=\"noindex, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"NSA | Injury Report\" \/>\n<meta property=\"og:url\" content=\"https:\/\/i9development.com\/Dev6\/resources\/forms\/injury-report-form\/\" \/>\n<meta property=\"og:site_name\" content=\"Nelson Soccer Association\" \/>\n<meta property=\"article:modified_time\" content=\"2026-04-14T15:40:22+00:00\" \/>\n<meta property=\"og:image\" content=\"https:\/\/i9development.com\/Dev6\/wp-content\/uploads\/2026\/01\/DJI_20251019095704_0085_D.jpg\" \/>\n\t<meta property=\"og:image:width\" content=\"800\" \/>\n\t<meta property=\"og:image:height\" content=\"600\" \/>\n\t<meta property=\"og:image:type\" content=\"image\/jpeg\" \/>\n<meta name=\"twitter:card\" content=\"summary_large_image\" \/>\n<meta name=\"twitter:label1\" content=\"Est. reading time\" \/>\n\t<meta name=\"twitter:data1\" content=\"14 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