Accident & Injury Report Form Survey

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* Please list all the events the athlete is scratching from:

Event 1:

Event 2:

Event 3:

Event 4:

Event 5:

Event 6:

Event 7:

Event 8:

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* Please specify if this Bye Request is medical or non-medical.

Medical - due to injury

Medical - due to illness

Non-Medical

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* Please explain why this Bye is being requested.

Please attached all supporting documentation - medical notes, travel itinerary, etc.

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* File 1

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

Choose File

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* File 2

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

Choose File

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* File 3

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

Choose File

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* Name of Person Submitting this Form:

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* Email of Person Submitting this Form:

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* Email of Club Head Coach:

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* Reporting Party Information:

Name

Affiliated Club

Role with Club

Email Address

Phone Number

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* Injured Party Information:

Name

Affiliated Club

Adress

City/Town

Province

Postal Code

Email Address

Phone Number

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* Injured Party Date of Birth

MM/DD/YYYY

Date

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* Injured Party Gender:

Female

Male

Non-Binary

Prefer not to say

Other (please specify)

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* Accident or Injury Information

Date of Incident

Time

Facility Name

Address

City/Town

Location within Facility (please be specific)

Activity at the time of incident

Activity Supervisor at the time of incident

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* Was the activity sanction/approved?

Yes

I Don't Know

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* Please describe the incident and how the injury/accident happened.

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* Please describe the injury including the affected body parts (please be specific).

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* Was on-site care given by a specialist?

Yes

I Don't Know

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* Name of person giving care

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* What care or treatment was given on-site?

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* Please select all that apply.

Parent/Guardian were notified.

Injured party was taken to a clinic/hospital.

Care was refused by the injured party.

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* If the injured party was taken to a clinic or hospital, please provide the location.

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* If care was refused by the injured party or their parent/guardian, please have them submit a written statement to this effect. A statement from the parent/guardian is required to all athletes under the age of 18.

The statement has been requested.

The statement has been submitted.

Not Applicable

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* Does the injured party have provincial health coverage?

Yes

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* Does the injured party have other insurance?

Yes

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* If yes, please provide the name of the insurance company.

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* Witnesses
Please include the names of two witnesses and attached the witness reports.

Witness 1 Name

Witness 1 Phone

Witness 1 Email

Witness 2 Name

Witness 2 Phone

Witness 2 Email

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* By entering your name in the box below, you are confirming that the information provided is complete and true to your knowledge.

Please upload witness statements, medical notes and any other documentation relevant to the incident.

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* File 1

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

Choose File

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* File 2

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

Choose File

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* File 3

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

Choose File

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* File 4

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

Choose File

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* File 5

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

Choose File

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* Event/Competition:

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* Member Club Affiliation

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* Athlete Full Name:

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* Athlete Date of Birth:

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* Athlete Age Group:

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* Athlete Stream:

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* Please list all the events the athlete is scratching from:

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* Please specify if this Bye Request is medical or non-medical.

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* Please explain why this Bye is being requested.

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* File 1

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* File 2

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* File 3

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* Name of Person Submitting this Form:

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* Email of Person Submitting this Form:

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* Email of Club Head Coach:

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* Reporting Party Information:

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* Injured Party Information:

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* Injured Party Date of Birth

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* Injured Party Gender:

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* Accident or Injury Information

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* Was the activity sanction/approved?

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* Please describe the incident and how the injury/accident happened.

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* Please describe the injury including the affected body parts (please be specific).

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* Was on-site care given by a specialist?

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* Name of person giving care

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* What care or treatment was given on-site?

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* Please select all that apply.

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* If the injured party was taken to a clinic or hospital, please provide the location.

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* If care was refused by the injured party or their parent/guardian, please have them submit a written statement to this effect. A statement from the parent/guardian is required to all athletes under the age of 18.

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* Does the injured party have provincial health coverage?

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* Does the injured party have other insurance?

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* If yes, please provide the name of the insurance company.

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* WitnessesPlease include the names of two witnesses and attached the witness reports.

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* By entering your name in the box below, you are confirming that the information provided is complete and true to your knowledge.

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* File 1

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* File 2

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* File 3

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* File 4

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* File 5

* Witnesses
Please include the names of two witnesses and attached the witness reports.