Incident Report Please enable JavaScript in your browser to complete this form. - Step 1 of 8Date / Time of IncidentDateTimeSummary of report. Describe in chronological order, including how and when you learned of the incident.NextInformation About the Injured PartyInjured Party's Name *FirstLastInjured Party's Phone *Injured Party's Age *Injured Party's Gender *Non-Binary | Transgender | NeutralFemaleMaleInjured Party's AddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeNextInured Party's Emergency Contact Information FirstLastName, Contact Numbers, Emails if you have them on fileEmail (1st Emergency Contact)Inured Party's Emergency Contact Information (2nd contact, if known)FirstLastName, Contact Numbers, Emails if you have them on fileEmail (2nd contact, if known)NextWhat Is the injured party's team name? *Injured Party's Youth Sports Company Name *Injured Party's Youth Sports Company Address *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeWhere does this team normally practice?Injured Party's Position on Team *Injured Party's Coach Names and contact information: *Provide names and contact inforrmation of each coach for the team.NextInformation About First Aid and Professional Medical CareWas any first aid required: *YesNoIf yes, by whom? *Please describe the first aid treatment provided: *Was professional medical treatment required? *YesNo(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? *YesNoYou 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.NextCPS / Law Enforcement Report InformationWhat is the name of the agency you reported this incident to? *Who did you speak to? Please provide an operator or badge number if you have it. *What is your report number? *What is the address of the agency you reported this incident to? *What is their phone number? *Did you report to a 2nd agency or sport federation? *YesNoPlease enter 2nd agency or sport federation contact details below.Did you report to a 3rd agency or sport federation?YesNoPlease enter 3rd agency or sport federation contact details below.NextDocumentation UploadsFile Upload - 2GB maximum per file. Files larger than 2GB need to be submitted through our upload link (Home page | Reports and Submissions | Documentation 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:Please provide link to large files:Please provide link to large files:Please provide link to large files:Please provide link to large files:Please provide link to large files:NextCONTACT INFORMATION FOR REPORTING PARTYReport prepared by *FirstLastEmployer or Affiliated Sport OrganizationPhone *Email (will receive copy of report) *Work Address *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeI wish to remain confidential *Keep my name confidential, but I understand that if law enforcement is required the reporters name must be provided to them.I am comfortable with my name on reports shared with the sport federation.Signature *Clear SignatureSubmit