Accident Report – Freedom Optimist Soccer

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.

Injured Party Information

Injured Person’s Name

Address

DOB

Phone

Location

Incident Date

Time

Injuries

Head

Face

Eye(s)

Ear(s)

Nose

Mouth

Teeth

Neck/Throat

Shoulder/Collar Bone

Back

Chest/Ribs

Abdomen

Arm(s)

Elbow(s)

Wrist(s)

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)

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.

Injured Party Information

Incident Details

Care Details

Witness Information

Your Information