Accident / Incident Report Please supply a copy of this report and any supporting documentation to the Christian Academy athletic office and notify Athletic Trainer of injury. Name of Athlete* First Last School* HS MS Elem AgeSport Date Occurred* MM slash DD slash YYYY Time : Hours Minutes AM PM AM/PM Place*Christian AcademyOff Campus EventSchoolPracticeGameHomeOtherDescription of accident*Action TakenCoach Supervising Event Yes No Third Choice Coaches Name* First Last Coach present at all of accident? Yes No Third Choice Parent/Guardian Contacted? Yes No Name & number of notified Did individual(s) involved seek medical assistance? Yes No If yes, from whom/where? Was disciplinary action taken as a result of this accident? Yes No Name of the person reporting First Last Phone of person reportingToday's Date MM slash DD slash YYYY
