Club Name

Please explain the incident providing as many details as possible*

Fixture at which incident took place (if applicable)

Age group of players (e.g. U10s / senior)

Were the match officials made aware of the incident? (if applicable)

Did the match officials take any action in response to the incident? (If applicable)

Were any other club officials made aware of the incident? (Including the opposition’s, if applicable)

Were there any other witnesses to the incident?

Have you contacted anyone else to inform them about the incident? (e.g. Area Association, Police)

Is there any additional information you would like to add?