SANCTIONED EVENT INFORMATION:
Federation/Club/Event Organizer’s Name: Insert name* Membership #: Insert number* Date(s) of Event: From* To* Address/Location of Event:Street Address* Address Line 2* City* State/Country* Zip*
SUBJECTS INVOLVED (attach additional reports if more than one person was involved):
Nationality/Country: Country* Federation: Federation
Note: Signed waivers are required for all participants in sanctioned events
DESCRIPTION OF ACCIDENT/INCIDENT/INJURY/ILLNESS (check all that apply):
Type of Event during which Incident/Injury occurred: Please specify*
Please answer the questions below and make use of the text blocks provided on this form to document additional details of this incident.
If so, what rating? Please specify
REPORT PREPARED BY:
ADDITIONAL DETAILS OF ACCIDENT/INCIDENT/INJURY/ILLNESS:
(Note - text boxes below are auto-fitting and unlimited)
FIRST AID TREATMENT AND DISPOSITION:
Name, Address and Telephone Number of Hospital or Other Medical Care Facility where transported?
Name of Hospital or Facility: Please specify