Esc Injury And Incident Report Form - Evansville Soccer printable pdf download

Evansville Soccer Club

Injury/Incident Report Form

Complete within 12 hours of incident/accident by referee/coach/team manager

Incident Date: _______________________________ Incident Time: ________________________

Person #1: ________________________________ Phone: ________________________________

Person #2: _________________________________Phone: ________________________________

Field Location: _ __________________________________________________________________

Male/Female: ___ Age (

): _________ Parent Name: _________________________________

if injury

Injury/Incident Type: _____________________________________________________________

Details of Incident: _______________________________________________________________

________________________________________________________________________________

Additional pages may be added as needed. Continued Y or N?

If injury, does the injury require Hospital/Physician? Yes: __ No: __ Taken by: __________________

Hospital Name: ______________________________________ Taken to Dr. by private car?: Y or N

Name of person transporting injured person ___________________________________________

Witnesses Name/Phone:

___________________________________________ / ____________________________________

Team Names: ____________________________ Coaches: ________________________________

Date: ______________________________ Signature: ___________________________________

Phone: _____________________________ Email: ______________________________________

Evansville Soccer Club maintains a zero tolerance policy of verbal or physical abuse, serious

breaches of unsportsmanlike conduct, fighting, or drug/alcohol use by players or

spectators. Please report serious incidents same day. Designate a responsible adult to

gather information if it occurs during a game so that the coaches and referees may

continue with their duties. Please note name of person who gathers pertinent information

in the incident description.

Return completed form to the Evansville Soccer Club referee coordinator or club President.

Esc Injury And Incident Report Form - Evansville Soccer