ONPARA ACCIDENT REPORT FORM
Complete this form whenever an accident/incident occurs which requires medical attention for an athlete, coach, official, volunteer or spectator. Please forward to the office of the Ontario Para Network. This is not a claim form, this form must be filled prior to a medical/dental claim being issued
Injured Participant Information
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Club Information
Club Name
*
Club Coach
*
Club Email
*
Club Phone
*
Incident Information *Check all that apply
*
Practice
Game
Club Sanctioned Event
ONPARA Sanctioned Event
Indoor
Outdoor
Other
Describe Activity
*
Date of Incident
*
-
Month
-
Day
Year
Date
Time
*
Hour Minutes
AM
PM
AM/PM Option
Location of Incident
*
Playing Surface
*
Weather Condition
*
Describe Incident in full detail
*
Type of Injury
*
Was treatment provided on site?
*
Yes
No
If yes, please provide the name and title of those who provided treatment:
*
Was outside medical/dental attention obtained?
*
Yes
No
If yes, please provide the name and title of those who provided treatment:
Was outside medical/dental follow up advised?
*
Yes
No
Submitted By
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Submit
Should be Empty: