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 ljathletic@gmail.com within 24 hours of incident
Lone Jack Athletic Association
PO Box 940176
Lone Jack MO 6407