Flagler Youth Athletic Association

Pop Warner Football and Cheer

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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 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*

Walmart

Quantum Electrical

Kevin A Peck, Inc.

Community Mortgage Solutions

Jacksonville Ortho Institute

Flagler Tax Services

Sunshine State Heating and Air

Olde Florida Title

Pave America Inc.

Bayne’s BBQ and Southern Kitchen

Flagler Bounce

Kona Ice

Hawkeye Brothers Signs, Graphics and Designs

Deland Kia

Daytona Toyota

Palm Coast Ford

Marlin Consulting Solutions

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Our Contacts

Football Email: FlaglerYAA@gmail.com

Cheer Email: FYAACheer@gmail.com