Club Sports Accident Report Form

Email Secondary Email

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Identification Information

Name (person involved in incident/accident) *

Class Year *

ID Number *

Gender *

Male Female

Date of Incident/accident *

Sport in which incident/accident occurred *

Location of incident/accident *

Time of incident/accident *

Describe injury (using left, right, etc.) *

Description of incident/accident *

Was immediate first aid administered? (Yes/No) If Yes, describe. *

Was person referred to Health Services? *

Yes No

Was Safety & Security notified for emergency transport? *

Yes No

Was person taken to hospital? *

Yes No

If yes, name of hospital.

Other actions taken at time of injury

Email address *

First name *

Last name *

Cell Phone Number

* required field

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