Incident/Injury Report

Person involved in incident:


Name:                                                                              Phone:                  




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: