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: