Cheer Athletics Charlotte Vendor Application - The Sports Compliance Company

Please prepare the any photos, videos, or security footage of event- you will upload it at the last page of this intake form.

Date / Time of incident *

Date

Time

Please describe the incident *

Youth Sports Company Name *

Youth Sports Company Address *

Address Line 1

Address Line 2

City

State

Zip Code

Where does this team normally practice?

Was the location of the injury different than the company address? *

Address of Injury

Address Line 1

Address Line 2

City

State

Zip Code

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Information About the Inured Party

Injured Party's Name *

First

Last

Injured Party's Age *

Injured Party's Gender *

Inured Party's Emergency Contact Information *

First

Last

Name, Contact Numbers, Emails if you have them on file

Coach Names and contact information: *

Provide names and contact inforrmation of each coach for the team.

What Is the injured party's team name? *

Injured Party's Position on Team *

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Information About First Aid and Professional Medical Care

Was any first aid required: *

If yes, by whom? *

Please describe the first aid treatment provided: *

Was professional medical treatment required? *

(If yes, the player must present a non-restrictive medical release prior to being allowed in a game or practice.)

If professional medical attention required, please describe: *

Was family member or emergency contact called? *

You answered yes. Who did you call, and what is their contact number? *

List name and contact information for family member or emergency contact you called.

Injury occurred while participating in: *

Tryout
Practice
Game | Competition (single day)
Tournament |Competition (multi-day)
Travel To Event
Travel From Event
Other

Other- Please provide detail

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Documentation Uploads

File Upload

Click or drag files to this area to upload. You can upload up to 10 files.

Upload any videos, photos, or link to security camera footage of the event if available.

Please provide link to large files:

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WHO PREPARED THIS REPORT

Report prepared by *

First

Last

Email *

Phone *

Work Address *

Address Line 1

Address Line 2

City

State

Zip Code

Signature *