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Incident Date:
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What sport was the injured person(s) participating in?
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Baseball
Basketball
Cheer
Softball
Rugby
Football
Tennis
Soccer
Volleyball
Golf
Other
What Age Group/Division?
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Field Name/ Location:
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Time of Incident:
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Injured Person's Name:
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Date of Birth:
Address:
Age:
Sex:
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Male
Female
Parent's Name (If Player):
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Parent's Address (If Different):
Home Phone:
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Injury Occurred To:
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Player
Coach
Official
Fan
Was the parent/guardian notified if not on the scene?
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Incident occurred during:
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Practice
Game
Tournament
Game-Warm Up
Type of Injury:
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Was Fist Aid Required:
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Yes
No
If Yes, What?
Was Professional Medical Treatment Required?
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Yes
No
If Yes, What?
Please give a short description of incident:
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Could this incident have been avoided? How:
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