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 president@howellsoccerclub.com.
Date of Incident *
MM
/
DD
/
YYYY
Time of Incident *
Time
:
Activity *
Location of Incident *
Injured's Name *
Your answer
Gender *
Injured's Age *
Your answer
Division *
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.)
Your answer
Describe the Incident *
Please describe what happened leading up to the incident.
Your answer
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.)
Your answer
Was an Ambulance Called? *
Remember to email president@howellsoccerclub.com immediately if an ambulance was called.
Did the Participant Return to the Activity? *
Submitter's Name *
Your answer
Submitter's Role *
Submitter's Email *
Your answer
Submitter's Phone Number *
Your answer
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