Eatonville Youth Sports Association

PARTICIPANT'S NAME

First name, last name

DATE OF INJURY

date injury occurred

TIME OF INJRY

time of injury

ACCIDENT LOCATION

location where injury occurred

FIELD/GYM NUMBER

BODY PART INJURED

note which body part was injured

TYPE OF INJURY

select type of injury here

FIRST AID GIVEN

select the type of first aid given

ACCIDENT TYPE

ACTION TAKEN

DESCRIBE ACCIDENT

Please describe how the accident happened.

WITNESS #1

First and last name of witness. Witness phone number.

REPORT SUBMITTED BY

Please enter your name

Referee Name

Cell Phone Number #1

Enter a number to receive text messages.

Cell Phone Number #2

Injury Report Form