Marlton Recreation Council

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Injury Report Form

Marlton Recreation Council Injury Report

* Required

Name of person filing report * Enter your full name

Date of incident/injury * Enter in the format of MM/DD/YYYY

Approximate time

Sport *

Location *

Coach w phone # *

Injured Party wPhone number * (XXX) XXX-XXXX

People Involved w phone # * Please list any names and phone numbers of ALL individuals involved

Specifically describe the injury * Please list as many details as possible

Contributing factors *

		Yes	No
Were there any factors that contributed to this injury?

If the answer the previous question is yes, please describe

Describe what actions were taken and who treated the injured individual(s) *

Medical Transportation *

		Yes	No
Was an ambulance called?

If the answer to the previous question is yes, to what hospital was the individual taken for treatment?