Combat Sports and Fitness Center, LLC
Accident / Incident Report
Report Type
*
Incident
Accident
Time
*
Hour Minutes
AM
PM
AM/PM Option
Date
*
-
Month
-
Day
Year
Date Picker Icon
Name Of Participant / Injured Party
*
First Name
Last Name
Age Of Participant / Injured Party
Name of Parent / Guardian (if applicable)
First Name
Last Name
Phone Number
*
FROM MEMBERSHIP SOFTWARE
Email
*
FROM MEMBERSHIP SOFTWARE
Staff Completing Form
*
First Name
Last Name
Phone Number
Area Where Accident / Incident Occured
*
(E.G. MAIN GYM, TURF/CLASS AREA, MEN'S LOCKER ROOM, WOMEN'S LOCKER ROOM, CARDIO AREA, PARKING LOT, ALLEY, ETC)
Description of Incident (BE AS DETAILED AS POSSIBLE)
*
Was EMS Called
*
Yes
No
Action Taken / Treatment Administered
*
(E.G. TAKEN TO HOSPITAL BY EMS, FIRST AID GIVEN, ICE PACK GIVEN, ETC)
List ANY Known Injuries Sustained
(E.G. HEAD TRAUMA, BLEEDING, CUTS, BROKEN BONES, ETC)
Witness 1
First Name
Last Name
Witness 2
First Name
Last Name
Submit
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