Incident/Injury Report

Person involved in incident:

 

Name:                                                                              Phone:                  

 

Address:

 

If minor, Parents information:

 

 


Date of Incident:                                                                        Time:          

 

Program/Recreation Council:

 

Name of Coach:                                                                Phone:

 


Location of Incident:                                               

 

Weather Conditions:

 

Incident/Damage Description:

 

 

 

 


Medical Attention:             Yes          No           Refused

 

Injury (Body Part):

 

Taken by ambulance:        Yes          No           Ambulance Company:

 

What medical facility/doctor:

 

Witness/Witnesses (name & phone numbers):

 

 

 

 


Signature & title of person completing report:

 

 


Printed Name:                                                                            Date: