Emergency Incident Report Form
New Sport National Template
Prepared by: Charity Helpers Foundation
Date: 2025-06-13
Version: 1.0

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**EVENT INFORMATION**

Event Name: ____________________________________________  
Date of Incident: _______________________________________  
Location of Incident: ____________________________________  
Event Organizer Name: ___________________________________

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**INDIVIDUAL(S) INVOLVED**

Name(s): ________________________________________________  
Role(s): ☐ Player ☐ Spectator ☐ Organizer ☐ Volunteer ☐ Other

Age (if under 18): ___________   Guardian present? ☐ Yes ☐ No

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**DESCRIPTION OF INCIDENT**

Describe in detail what happened, including sequence of events and any immediate actions taken:

_______________________________________________________  
_______________________________________________________  
_______________________________________________________  
_______________________________________________________  
_______________________________________________________  

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**INJURY / PROPERTY DAMAGE REPORT**

☐ No injury  
☐ Minor injury  
☐ Serious injury  
☐ Emergency services contacted  
☐ Property damage involved

Description of injury or damage:

_______________________________________________________  
_______________________________________________________  

Was first aid provided? ☐ Yes ☐ No  
If yes, by whom: ________________________________________

Was 911 called? ☐ Yes ☐ No      Report Number (if any): ____________

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**WITNESS INFORMATION**

Name: _________________________________________________  
Phone/Email: ___________________________________________  
Statement (or attach separate page):  
_______________________________________________________  
_______________________________________________________  

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**FOLLOW-UP / ACTIONS TAKEN**

☐ Guardian notified  
☐ Participant removed from event  
☐ Authorities involved  
☐ Additional documentation filed

Notes:

_______________________________________________________  
_______________________________________________________  

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**SIGNATURE OF ORGANIZER COMPLETING THIS FORM**

Signature: _____________________________________________  
Print Name: ____________________________________________  
Date: _________________________________________________

Submit this form to Charity Helpers Foundation administration within 48 hours of incident.