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Injury Report
Please fill out this form when an injury occurs 
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Email *
Incident date *
MM
/
DD
/
YYYY
Incident Time *
Time
:
Injured Person's Name  *
Date of birth *
MM
/
DD
/
YYYY
Injured Person's address  *
Injured Person's phone number or parent phone number *
Parent's Name and address (if different) *
Field Name/location *
Position/Role of person(s) involved in the incident  *
Type of injury *
Was first aid required? *
If yes, what was needed in regards to first aid? *
Was professional medical treatment required? *
Type of incident and location *
Please give a short description of incident *
Could this accident have been avoided? How *
Please type for full legal name in lieu of your signature *
Today's date *
MM
/
DD
/
YYYY
A copy of your responses will be emailed to the address you provided.
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