Safety Report

Field Name/Location

Injured Person's Name

Date of Birth

Age

Gender

Male

Female

Address

City

Zip

Parent's Name (if Player)

Parent's Address (If different)

Home Phone

Other Phone (work/mobile)

Incident occured while participating in

Baseball

Softball

Challenger

TAD

Division

Team:

Event type

Other event type:

Type of Injury:

Was first aid required?

Yes

No

Describe first aid

Was professional medical treatment required?

Yes

No

Describe medical treatment.

If medical treatment was required, the player must present a non-restrictive medical release prior to to being allowed in a game or practice.

Type of incident and location:

On Primary Play Field

Adjacent to Playing Field

Concessions Area

Off Ball Field

On Primary Playing Field

Base Path

Running

Sliding

Hit by Ball

Pitched

Thrown

Batted

Collision With:

Player

Structure

Other:

Adjacent to Playing Field

Seating Area

Parking Area

Concession Area

Volunteer Worker

Customer/Bystander

Off Ball Field

Travel

League Activity

Other

Travel

Car

Bike

Walking

Other:

Please give a description of the incident:

Could this accident have been avoided? How?

Prepared By/Position

Phone

Signature

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