Abbotsford Juniors Football Club - Injury Report Form
This form should be used by AJFC members to report any incident that occurs as part of a Club-related activity. Incidents involving any AJFC member player, coach, manager, parent or supporter should be reported.
Date of Incident
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
The date that the injury occurred
Location
*
Team Name
*
Age Group/Division/Group
Primary Player/Member Name Involved
*
First Name
Last Name
Parent Name (if Player/Member is Under 18 years)
First Name
Last Name
When did the incident occur?
*
Please Select
Regular Season Game
Team Training
Pre-Season Game
Post Game
Other
Description of Incident
*
Please include as much detail as possible
Match Official Present
Yes
No
Ground Official Present
Yes
No
Match Official Detail
(to be completed if present)
Match Official Type
Match Official's Name
Noted by Match Official in Match Sheet?
Yes
No
Ground Official Name
First Name
Last Name
Ground Official Club
Name of the Club of the Ground Official
Witness Detail(s)
Witness 1 Name
First Name
Last Name
Witness 1 Email
example@example.com
Witness 1 Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Witness 2 Name
First Name
Last Name
Witness 2 Email
example@example.com
Witness 2 Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Reporter Detail
Reporter Name
*
First Name
Last Name
Reporter Email
*
example@example.com
Reporter Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Role in the Club
*
Committee Member
Team Coach
Team Manager
Parent/Family member
Other
Please verify that you are human
*
Submit
Should be Empty: