Incident Report

FYAA Injury Incident Report

Date of Incident*
Reporting date of Incident*
Time of Incident*
Remember to put AM or PM
Location of Incident*
Participant's Last Name*
Participant's First Name*
Participant's Address*
City/State/Zip*
Date of Birth*
Phone Number*
Sex*
- Male
- Female
Part of Body Injured*
Description of Incident*
Date of First Medical Treatment*
Email Address*
Which Sport?*
- Cheer
- Football
Sport Designation*
- Practice
- Game
- Event
Action Taken*
- Released to Parent
- Ambulance Transport
- Referred to Hospital/Clinic
- Own Accord(Adult)
Which Hospital?*
Claimant Designation*
- Coach/Manager
- Volunteer
- Spectator
- Participant
- Umpire/Referee
Team*
Was the claimant supervised when injured?*
- Yes
- No
By Who?*
Was injury during travel to or from scheduled activity in a supervised group?*
- Yes
- No
Is Participant/Claimant a Minor?*
- Yes
- No
Father/Guardian's Name*
Mother/Guardian's Name*
Same Address for Participant/Parent/Guardian*
- Yes
- No
Address for Parent/Guardian if different then Participant*
Same Phone Number for Participant/Parent/Guardian*
- Yes
- No
Phone 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?*
- Yes
- No
Mother/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?*
- Yes
- No
Submitted by*
Please put full name
Title*
Other Title*