Accident / Incident Report

Name of Athlete*

First Last

School

Age*

Sports*

Date of Injury*

Time of Injury*

: HH

MM

Place*

Description of Accident*

Action Taken*

Coach Supervised Event

Coach's Name*

First Last

Coach Present at the Scene of the Accident?

Parent/Guardian Contacted?

Name and Number of Parent/Guardian Notified*

Did Individual(s) Involved Seek Medical Assistance?

If Yes, from Whom/Where?*

Was Disciplinary Action Taken as a Result of this Accident?

Name of Person Reporting*

First Last

Phone of Person Reporting*

Today's Date