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Info

Accident Report

Name

Please complete and submit the following form to report any injuries or accidents that occurred during a Freedom Optimist Soccer activity. A copy of the report will be sent to Freedom Optimist Soccer, to the Freedom Area Rec Council if necessary, and to your email address.

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Injured Party Information

Injured Person’s Name *

Address *

Email *

DOB

Phone *

Incident Details

Location *

Incident Date *

Time *

Injuries

Head

Face

Eye(s)

Ear(s)

Nose

Mouth

Teeth

Injuries (cont)

Neck/Throat

Shoulder/Collar Bone

Back

Chest/Ribs

Abdomen

Arm(s)

Elbow(s)

Wrist(s)

Injuries (cont2)

Hand(s)

Finger(s)

Leg(s)

Knee(s)

Ankle(s)

Feet

Toe(s)

Other

Description *

Notification Procedure (required for injured minor)

In Person By Phone Email If the injured was under 18, how were their Parents/Guardians notified?

Notification Date

Time

Care Details

Did any staff or volunteer provide care?

Name (of Staff or Volunteer Providing Care)

Email (of Staff or Volunteer Providing Care)

Phone (of Staff or Volunteer Providing Care)

Ambulance

Was an Ambulance Called?

Any Hospital or Medical Contact Provided?

Care Given

Witness Information

Were there any witnesses to the incident or care provided?

Witness 1 Name

Phone

Address

Witness 2 Name

Phone

Address

Your Information

Your Name *

(Your name also acts as your form signature)

Your Email Address *

Your Phone *

Please allow for up to a minute for the PDF report generation and submissions process and only click Submit once. Thanks.

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Freedom Optimist Soccer is an organization of volunteers who work with the Freedom Area Recreation Council and the Carroll County Department of Recreation and Parks to provide recreation opportunities in the Sykesville and Eldersburg area, as well as surrounding areas. The Americans with Disabilities Act applies to the Carroll County Government and its programs, services, activities, and facilities. Anyone requiring an auxiliary aid or service for effective communication or who has a complaint should contact The Department of Citizen Services, 410.386.3600 or 1.888.302.8978 or MD Relay 7-1-1/1.800.735.2258 or email ada@carrollcountymd.gov as soon as possible but no later than 72 hours before the scheduled event.