SAGFA Incident Report

1

In the event of an actual EMERGENCY always call 911 first.

This form is to provide direct notification to the Board of Directors of any relevant incidents that have transpired.

Please understand that the Board may not respond back to you directly, but all reports are shared with the entire Board of Directors.

If you have further questions or concerns, please contact your division coordinator.

2

Reporting Party Name

First Name

Last Name

3

Reporting Party Phone Number

Area Code

Phone Number

4

Email

example@example.com

5

Please Provide the Date of the Incident* This field is required.

Date

6

Please Provide the Time of the Incident* This field is required.

Hour

Minutes

8

Please Select Type of Incident* This field is required.

Player Injury

Player Misconduct

Spectator Injury

Spectator Misconduct

Coach/Volunteer Misconduct

Umpire Misconduct

Board Member/Coordinator Misconduct

Other Concerns

9

Please list the name(s) of who caused the incident (if any)* This field is required.

10

Please list the name(s) of the affected party (if any)* This field is required.

11

Please describe in detail what transpired* This field is required.

12

Acknowledgment* This field is required.

I acknowledge and agree that all statments contained in this report are true, accurate, and correct to the best of my knowledge and understanding.

13

Contact* This field is required.

I understand that I may not be contacted directly by a representative of SAGFA, but all incident reports are provided to the entire Board of Directors for review.

14

Request for Contact

Though I acknowledge and understand that my request for contact by a representative of SAGFA may not be able to be accommodated, I am requesting that a Board Member/Coordinator contact me directly, if available.

15

Request for Anonymity

I am requesting that SAGFA, and the Board Members, keep my identity anonymous to anyone outside of the Board of Directors, to the extent that it can be reasonably accommodated.

16

By my signature below, I agree that all information contained in this report is true, accurate, and correct to the best of my knowledge and I agree to the aforementioned terms.* This field is required.

Clear

17

Enter the message as it's shown* This field is required.