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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
:

Last

First

MI
:
:
xxx-xxx-xxxx
xxx-xx-xxxx
:
:    
:
Does the injured person have other medical insurance?
If yes, please provide name of company and policy #
:
:
:   :
:
:
:

 

GUARDIAN/PARENT (if injured person is a minor)
:

Last

First

MI
:
:
xxx-xxx-xxxx

 

INCIDENT INFORMATION
:
:
:
:Was ankle -
:Was knee -
:
:
:
:
:
:
Was a Police Report Filed?:
:
:
:

 

WITNESS INFORMATION
:
:
:
: xxx-xxx-xxxx

:
:
:
: xxx-xxx-xxxx

:
:
:
: xxx-xxx-xxxx

:
:
:
: xxx-xxx-xxxx

 

PERSON COMPLETING FORM INFORMATION
:
: (e.g. Coach, Referee, Commissioner, etc.)
:
: xxx-xxx-xxxx