Incident Report FYAA Injury Incident Report FYAA Injury Incident Report Date of Incident*Reporting date of Incident*Time of Incident*Remember to put AM or PMLocation of Incident*Participant's Last Name*Participant's First Name*Participant's Address*City/State/Zip*Date of Birth*Phone Number*Sex*MaleFemalePart of Body Injured*Description of Incident*Date of First Medical Treatment*Email Address*Which Sport?*CheerFootballSport Designation*PracticeGameEventAction Taken*Released to ParentAmbulance TransportReferred to Hospital/ClinicOwn Accord(Adult)Which Hospital?*Claimant Designation*Coach/ManagerVolunteerSpectatorParticipantUmpire/RefereeTeam*Tiny-Mite CheerTiny-Mite FootballMitey-Mite CheerMitey-Mite FootballJr. Pee Wee CheerJr. Pee Wee FootballPee Wee CheerPee Wee FootballJr. Midget CheerJr. Midget FootballMidget CheerMidget FootballChallenger CheerWas the claimant supervised when injured?*YesNoBy Who?*Was injury during travel to or from scheduled activity in a supervised group?*YesNoIs Participant/Claimant a Minor?*YesNoFather/Guardian's Name*Mother/Guardian's Name*Same Address for Participant/Parent/Guardian*YesNoAddress for Parent/Guardian if different then Participant*Same Phone Number for Participant/Parent/Guardian*YesNoPhone number if Different then Participant*Father/Guardian's Employer*Place N/A if not applicable.Father/Guardian's Employer's Address*Place N/A if not applicable.City/State/Zip*Place N/A if not applicable.Father/Guardian's Work Phone Number*Place N/A if not applicable.Father/Guardian's Employer Medical Insurance Policy*Provide Insurance Company Name and Policy Number Place N/A if not applicable.Is Participant Covered under this Policy?*YesNoMother/Guardian's Employer*Place N/A if not applicable.Mother/Guardian's Employer's Address*Place N/A if not applicable.City/State/Zip*Place N/A if not applicable.Mother/Guardian's Work Phone Number*Place N/A if not applicable.Mother/Guardian's Employer Medical Insurance Policy*Provide Insurance Company Name and Policy Number Place N/A if not applicable.Is Participant Covered under this Policy?*YesNoSubmitted by*Please put full name Title*ParentCoachTeam ParentBoard MemberTrainerOtherOther Title*