Incident - Report Form - Spartans Soccer Club & Academy

Incident - Report Form

Complete this form and submit immediately for all incidents (e.g., accidents in parking lots, unruly sidelines, physical or verbal confrontation between coaches, players, or spectators, confrontations directed at referees or tournament officials, theft or vandalism), and any incident that could become a potential insurance claim or lawsuit.

Full Name

E-mail

Phone Number

Location of Incident/Accident

Date of Incident/accident*

Date of Incident/accident

Time of incident/Accident Hour : Minute AM or PM

Type of Incident/Accident

Bodily Injury
Property Damage

Event : e.g. League Game, Friendly Game, Tournament etc.*

Specific Location (Field, Parking Lot, Gym etc.)*

BODILY INJURY REPORT

Name of Injured Person (if applicable)

Sex (if applicable)

F
M

Contact phone number of the injured person

Email of the injured person

Description of injury and parts of body injured

Brief summary of incident (provide facts only)

Did injured person make any statement? YES or NO. If Yes, please describe what was said below:

Yes
No

If Yes, please describe what was said below.

Was first aid administered? YES or NO

Yes
No

If Yes, by whom? (Name and Position)

Were paramedics called? YES or NO

Yes
No

Paramedic services offered? Accepted or Refused

Accepted
Refused

Were police called? YES or NO

Yes
No

Name of Officer(s) and Department?

Were Parents/Guardians/Relatives notified? YES or NO

Yes
No

By whom? Contact details, Phone and email.

Name of Parent/Relative contacted

Relationship to injured person

Relative/Guardian Phone Number

Relative/Guardian Email

Do you expect this person to submit a claim? YES, NO, Do Not Know

Yes
No
Do Not Know

DAMAGE/THEFT OF PROPERTY REPORT

Name of property owner

Contact phone number of property owner

Email of property owner

Describe property damage

Summarize how damage occurred or what was stolen. (Provide facts only)

COMPLETE WITNESS INFORMATION

Name of Witness

Witness phone number

Witness Email

If applicable, relationship to injured party: Relative/Friend (Specify)

Did witness make any statement? YES or NO.

Yes
No

If Yes, please describe what was said below

Upload any relevant files, reports, pictures etc.