Howell Soccer Club Accident/Injury Report
Please report all injuries within 24 hours of the occurrence. This includes injuries to all spectators, players, or coaches during practices and games. If the incident requires a call to 911, please complete this form and report it immediately to
Date of Incident
Time of Incident
Location of Incident
Oak Glen Park Field 1
Oak Glen Park Field 2
Oak Glen Park Field 3
Oak Glen Park Field 3A
Oak Glen Park Field 3B
Oak Glen Park Field 4
Oak Glen Park Field 5A
Oak Glen Park Field 5B
Oak Glen Park Field 5C
Oak Glen Park Field 5D
Middle School South
Middle School North
Aldrich Elementary School
Land O' Pines Elementary School
Newbury Elementary School
Ramtown Elementary School
Tauton Elementary School
Prefer not to say
What is the Nature of the Injury?
(Ex. Hurt Right Leg, Head Injury, Rolled Left Ankle) - DO NOT DIAGNOSE; Do not use words such as "Fractured" or "Broken". Please give us a direction (left or right) and body part (arm, wrist, leg, ankle, knee, head, etc.)
Describe the Incident
Please describe what happened leading up to the incident.
What Action was Taken and by Whom?
Tell us what treatment was given at the field. (Ice, Ambulance Called, Someone Drove Player to Doctor/ER, ETC.)
Was an Ambulance Called?
Remember to email
immediately if an ambulance was called.
Did the Participant Return to the Activity?
Yes, but later left the activity again due to the same injury.
Submitter's Phone Number
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