Date of incident:                                Time:                   AM/PM Location:                                                                                                        

Site Director:                                                                                  

Nature of Event:                                                                              

Name of injured person:                                                                                                                                Address:                                                                                                                          Phone Number(s):                                                                                                                                                                       Date of birth:   Male                   Female                                                        

Grade                                                  School                                                                                     Who was injured person? (circle one) Player                                   Spectator          Coach

Type of injury:                                                                                                                                         Details of incident and injury (use back of sheet if necessary):                                                                                                                                       

Parent Present? Yes            No                        Parent Notified? Yes            No             Paramedics called to scene? Yes           No          

Who contacted fire rescue to scene?                                                                                      Injury requires transport?                                                       Yes           No          

Name of physician/hospital:                                                                                                                                         Address:                                                                                                                                         Physician/hospital phone number:                                                                                                                                       

Name and Signature of Person completing this report                                                                                                                                                                   Date

Email this completed form to within 24 hours of incident

Lone Jack Athletic Association

PO Box 940176

Lone Jack MO 6407