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Santa Teresa Little League
San Jose,CA
Division 2 | Section 5 | District 59
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Safety Report
Field Name/Location
Incident Date/Time
Date
E.g., 2017-10-21
Time
E.g., 11:40 pm
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
6U
8U
10U
12U
13U
15U
Challenger
Other
Team:
Event type
Tryout
Practice
Game
Tournament
Special Event
Travel to
Travel from
Other
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
Hit by Ball
Collision with:
Grounds Defect
Other
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
User login
Username
*
Password
*
Create new account
Request new password
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