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Orange County SportsPlex <br />INCIDENT REPORT FORM <br /> <br /> <br />Date Of Report:____________________ Date of Incident:______________________ <br /> <br />Time of Incident:___________________ AM PM <br /> <br />Facility: Orange County SportsPlex Phone: (919) 644-0339 <br /> <br />Address: 101 Meadowlands Drive Hillsborough, NC 27278 <br /> <br />Personal Data- Injured Party <br />Name: _______________________________________ Age: _______ Male Female <br /> <br />Address:____________________________ City: _____________ State: ____ Zip:____ <br /> <br />Phone Numbers: (h) _____________________ (w)_______________________ <br /> <br />Family Contact: (Name): _______________________ Phone #: ____________________ <br /> <br />Incident Data <br />Location of Incident: ___________________________________________ <br /> <br />Description of Incident: (ex: fell hit head on the ice while skating) <br /> _______________________________________________________________________ <br />________________________________________________________________________ <br /> <br />Was an injury sustained? Yes No <br /> <br />If yes, describe the type of injury sustained: (ex: 3 inch long, ½ inch deep cut to chin) <br />_______________________________________________________________________ <br />_______________________________________________________________________ <br /> <br />Witnesses: <br />1. Name: ______________________________ Phone #: _________________________ <br /> <br />Address: ________________________City: _____________ State: ____ Zip: ________ <br /> <br />2. Name: ______________________________ Phone #: ________________________ <br /> <br />Address: ________________________City: _____________ State: ____ Zip: ________ <br /> <br />Docusign Envelope ID: 177AA06A-30B4-42FF-A85A-78B5A7C51DBE