Incident Report Form

Pasadena | Altadena | La Cañada

Featured Sponsors

Click Logo for more Information

Email Alerts

More Info | Subscribe

Field Closures/
Game Changes

No current field closures or schedule changes.

Random Photo

Headlines
Intermediate and Advanced Coaching Courses -- UPDATED 7/11

Referee Courses Now Available

Summer Camps!!

BU10 Regional Team Completes Remarkable Run

Incident Report

In the event of an accident or injury before, during or after a scheduled AYSO function, please complete this form. The form is long, but you must complete all sections before submitting. The information you supply will be emailed to the Region 13 Commissioner and the Safety Director. If you prefer, you may download a copy of the form, fill it in and return it to the Commissioner or Safety Director. Mail the completed form to:

AYSO Region 13
Safety Director
711 W. Woodbury Rd., Unit E
Altadena, CA 91001

SECTION: 1 AREA: C REGION: 13

INJURED PERSON INFORMATION/PROPERTY DAMAGE OWNER

Name:

Last

First

Address:

City, State, Zip:

Phone

xxx-xxx-xxxx

Social Security #

xxx-xx-xxxx

AYSO ID#:

Age / Date of Birth / Sex:

Male Female

Team Name:

Does the injured person have other medical insurance?

Yes No

If yes, please provide name of company and policy #

Company:

Policy #:

Injured Person Was A:

If Other:

Employer's Name:

Employer's Address:

Employer's City, State, Zip:

GUARDIAN/PARENT (if injured person is a minor)

Name:

Last

First

Address:

City, State, Zip:

Phone

xxx-xxx-xxxx

INCIDENT INFORMATION

Date of Incident:

Time of Incident:

Body Part Injured:

If Ankle Injury:

Was ankle - Shoes?

If Knee Injury:

Was knee - Knee Pads?

Primary Injury:

Location:

Type of Incident:

Dispostion:

Field Surface:

Classification:

Was a Police Report Filed?:

Yes No

If yes, report number:

Officer's Name:

Describe how the incident, injury or property damage occurred:

WITNESS INFORMATION

Witness 1 Name:
Address:
City, State, Zip:
Phone:	xxx-xxx-xxxx
Witness 2 Name:
Address:
City, State, Zip:
Phone:	xxx-xxx-xxxx
Witness 3 Name:
Address:
City, State, Zip:
Phone:	xxx-xxx-xxxx
Witness 4 Name:
Address:
City, State, Zip:
Phone:	xxx-xxx-xxxx

PERSON COMPLETING FORM INFORMATION

Your Name:
Title:	(e.g. Coach, Referee, Commissioner, etc.)
Your Email:
Your Phone:	xxx-xxx-xxxx

Menu

Featured Sponsors

Field Closures/Game Changes

Random Photo

Headlines

Field Closures/
Game Changes