Incident Report

The Significant Incident Report is to report issues that have been observed during Axemen Lacrosse Association events that you wish to report to the Axemen Lacrosse Association. Please use the Injury Report Form to report any injuries.

Date and Time of Incident *

/ Day / Month Year

at

: Hour Minutes

Location Of Incident

If location is "other" please specify location and address in the Summary of the Incident.

Age Group *

Team *

CDLA Game Number

Home Team *

Visiting Team *

Type of Incident *

Role of Person Involved *

Name of Primary Individual Involved *

First Name Last Name

Phone Number

- Area Code Phone Number

E-mail of Primary Individual Involved

DETAILS AND EXPLANATION OF INCIDENT *

Please supply factual information. Opinions on the situation are not needed.

Game Officials

If Available

Game Officials Phone Numbers

- Area Code Phone Number

If Available

- Area Code Phone Number

Name of Others Involved In Incident

name/team/position on the team and contact information if available

Is the person reporting the Significant Incident doing so on the behalf of a minor *

Yes No

Name of Adult Completing Form

First Name Last Name

Phone Number

- Area Code Phone Number

E-mail

Relationship To Minor

Is The Minor An Axemen Player

Yes No

Name of minor

First Name Last Name

Phone Number

- Area Code Phone Number

E-mail

Axemen Lacrosse Association will provide organized lacrosse programs that will develop, support, and enrich all our members. Respect, responsibility, sportsmanship, fairness, commitment, and the spirit of friendly competition are foundational to the game of Lacrosse. Those involved at all levels should strive to uphold these principals. For Axemen Lacrosse Association players, coaches, parents and volunteers we believe these qualities are essential for success, enjoyment and athletic growth. Therefore; the Axemen Lacrosse Association holds ourselves accountable for our actions that in the eyes of others are detrimental to the game of lacrosse.

Significant Incident Report

Reporting Person's Information