ACCIDENT REPORT No.
Date:□ Other (please state)
Injured Person: Name:
□ Male □ Female Date of Birth: Phone: Email:
Address:
□ Athlete □ Coach □ Spectator □ Volunteer (state role)
Parent / Guardian (If injured person is a minor - Under 16) Name:
□ Male □ Female Phone: Email: Address:
Accident/Incident Information
Name of Event where incident occurred:Event Address / Location: Specific Location of incident:
Classification: □Non-Injury □ Minor Injury □ Serious Injury Describe the injury and how it occurred (use a separate sheet if necessary):
Disposition: No care given: □ Patient refused □ Not required
Released: □ To parent □ To personal vehicle □ To other: Referral: □ To doctor □ To hospital/clinic □ Not required
Ambulance: □ Required □ Patient requested
Witness Information Name: □ Not required Phone: Email: Position:
Person completing this report:
I declare that to the best of my knowledge, the information provided in this report is true and correct.
Name:
Phone: Email: Position: Signature:
Send completed form to: