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Incident Report

INSTRUCTIONS:   Please complete the entire report.  Once completed submit the form at the bottom of the page.  You will receive a confirmation page that will include a copy of the information submitted.  Keep this for your use should further information be needed.  A copy of the report will be forwarded to the Sports Commissioner of the League and the LYA Executive Board.  You will be contacted if additional information is required or when the incident has been resolved.

Name:                                                                     Date:          

Address:               

                                

Home Phone:       

Work Phone:       

Sport Involved:            League:         Date of Incident:     

Person(s) Involved:   

Name:           Phone:    

Name:           Phone:    

Description of Incident:

Witness(es) to the Incident:

Name:            Phone:         

Name:            Phone:       

What action did you take to resolve the incident?