GCRLRA School Games Send Off Form

GCRLRA School Games Send Off Form

This form must be completed for each individual whenever you have dismissed a player or need to report any other type of incident.
Officials Name *

First Name Last Name
Email *
example@example.com
Incident Date *

Day Month Year
Date
Ground *
Grade *
Select most appropriate age and competition from list
Did a Touch Judge witness the incident? *

Yes No
Did a Touch Judge make the initial report?

Yes No
Offending Player Name if known

First Name Last Name
Player Number
Offending Team
Time of Incident *
Eg 23mins into the first half would be 1/23
Describe the incident in detail *
Be very specific and descriptive in your report. Include any other identifiable features if not a player. Use the exact wording that was used (including swear words) if applicable.
Choose all charges that apply? *

15.1.(a) Trips, Kicks, Strikes another player 15.1.(b) When effecting or attempting to effect a tackle makes contact with the head or neck of an opponent intentionally, recklessly or carelessly 15.1.(c) Drops knees first to opponent who is on the ground 15.1.(d) Use any dangerous throw when effecting a tackle 15.1.(e) Deliberately and continuously breaks the laws of the game 15.1.(f) Uses offensive or obscene language 15.1.(g) Disputes the decision of the referee or touch judge 15.1.(h) Re-enters the field of play without the permission of the referee or touch judge having previously temporarily retired from the game 15.1.(i) Behaves in any way contrary to the true spirit of the game 15.1.(j) Deliberately obstructs an opponent who is not in possession 15.1.(k) Uses a shoulder charge on an opponent 15.1.(l) Applies any unnecessary pressure or twists, including grapples, crushers or performs a 'chicken wing' style hold on a player in possession 15.1.(m) Forcefully spears at the legs of a player in possession, exposing them to unnecessary risk of injury (Cannon Ball)
15.1.(a) Trips, Kicks, Strikes another player

Trips player by sticking foot out Trips player using ankle tap ( Safe Play Code U6 - U15) Kicks player - Lashes out with feet in ruck Kicks player - Uses knee or foot on player who is getting to their feet Kicks player - Uses feet to attempt to stop try scoring opportunity Strikes player with open hand Strikes player with fist Strikes player with elbow Strikes player using Head Butt Other
15.1.(a) Trips, Kicks, Strikes another player - Was player provoked?

Yes No
15.1.(a) Trips, Kicks, Strikes another player - Was player the instigator?

Yes No
15.1.(a) Trips, Kicks, Strikes another player - Was player the aggressor?

Yes No
15.1.(a) Trips, Kicks, Strikes another player - Was player defending themself?

Yes No
15.1.(a) Trips, Kicks, Strikes another player - Did player run from a distance?

Yes No
15.1.(b) When effecting or attempting to effect a tackle makes contact with the head or neck of an opponent intentionally, recklessly or carelessly - How was contact made?

Head High Tackle Swinging Arm Crusher Tackle Make contact with Elbow Head Lock (Grapple) Hair Pull
15.1.(b) - Was the Player on the ground?

Yes No
15.1.(b) - Was the tackle :

Intentional - Meant to make contact or went out of their way to make contact Reckless - No regard / aggressive Careless - Accidental Not Sure
15.1.(c) - Drops knees - Was the contact intentional?

Yes No Unsure
15.1.(c) - Drops knees - Was the player tackled?

Yes No
15.1.(c) - Drops knees - Had the player surrendered?

Yes No
15.1.(c) - Drops knees - Had the player scored a try?

Yes No
15.1.(c) - Drops knees - Was the player attempting to score a try?

Yes No
15.1.(c) - Drops knees - Did player slide in with knees and make contact with attacking player?

Yes No
15.1.(d) - Dangerous Throw - Was the player put in a dangerous position?

Yes No
15.1.(d) - Dangerous Throw - Was the player a kicker?

Yes No
15.1.(d) - Dangerous Throw - Was the player tackled in the air?

Yes No
15.1.(d) - Dangerous Throw - Was there hands between the players legs?

Yes No
15.1.(d) - Dangerous Throw - Was the player driven?

Yes No
15.1.(d) - Dangerous Throw - Was the player dropped?

Yes No
15.1.(d) - Dangerous Throw - Did offending player(s) land on top of opposition player?

Yes No
15.1.(d) - Dangerous Throw - How many players were in the tackle?

1 2 3 4
15.1.(f) - Offensive or Obscene Language - Was the language directed towards another player?

Yes No
15.1.(f) - Offensive or Obscene Language - Was the language directed towards an official?

Yes No
15.1.(f) - Offensive or Obscene Language - Was language directed towards the crowd?

Yes No
15.1.(f) - Offensive or Obscene Language - Was the language a racial slur?

Yes No
15.1.(f) - Offensive or Obscene Language - Was the language related to a players sexuality ?

Yes No
15.1.(f) - Offensive or Obscene Language - Was the language a threat?

Yes No
15.1.(h) - Player re-entering field of play - Was the player from the bench?

Yes No
15.1.(h) - Player re-entering field of play - Had the player been dismissed or was in the Sin Bin at the time of the incident?

Yes No
15.1.(h) - Player re-entering field of play - Did the player get involved in a melee / scuffle or fight?

Yes No
15.1.(h) - Player re-entering field of play - Approximately how far did the player encroach on the field?
15.1.(i) - Contrary Conduct - Choose all that apply *

Biting Spitting Eye Gouging Pinching Squirrel Grip Hip Drop Interfering with prone player Make contact with official Abuse Official Coach, Water Runner, First Aid, Bench Behaviour Action not in the true spirit of the game (Must be selected) Other
15.1.(i) - Contrary Conduct - How did you become aware of the incident?

I witnessed the incident Touch Judge witnessed the incident Player reported the incident
15.1.(i) - Contrary Conduct - Spitting - Was it deliberate?

Yes No
15.1.(i) - Contrary Conduct - Spitting - Did the spit make contact with another person?

Yes No Other
15.1.(i) - Contrary Conduct - Spitting - Where did the Spit land?

Skin of Face or Neck Skin of Arm or Hand Skin of Leg On Playing Uniform On Ground In the air Unsure Other
15.1.(i) - Contrary Conduct - Biting - Did you see bite marks?

Yes No
15.1.(j) - Deliberately Obstructs Opponent not in possession

Pushed opponent while contesting the ball Blocked support runner Escort runner Hold back support runner Tackled player not is possession Other
15.1.(k) - Shoulder Charge Opponent - Was contact deliberate or incidental?

Deliberate Incidental
15.1.(k) - Shoulder Charge Opponent - Was the player in possession of the ball?

Yes No
15.1.(k) - Shoulder Charge Opponent - Was the player hit late after offload?

Yes No
15.1.(k) - Shoulder Charge Opponent - Was the shoulder charge on a kicker?

Yes No
15.1.(k) - Shoulder Charge Opponent - Was the kicker in the air?

Yes No
15.1.(k) - Shoulder Charge Opponent - Was the player in the process of scoring a try?

Yes No
15.1.(k) - Shoulder Charge Opponent - Was contact made on the opposition players head?

Yes No
15.1.(k) - Shoulder Charge Opponent - Was the player on the ground?

Yes No
15.1.(l) - Applies unnecessary pressure or twists

Player performed grapple tackle Player performed crusher tackle Player performed chicken wing tackle Player performed a hip-drop Other
15.1.(m) - Forcefully spears at the legs - Was contact 1 on 1?

Yes No
15.1.(m) - Forcefully spears at the legs - Was player 2nd or 3rd man in?

Yes No
Please verify that you are human *
Should be Empty:

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