San Jose Police Activities League
680 S. 34th St.
San Jose, CA, 95116
408-272-9725  
408-272-9730 Fax

INJURY REPORT
Please complete immediately and turn in to Snack Shack Candy window.

ACTIVITY: _Girls Softball___  LEAGUE: ____West Valley PAL________________________________


Name of Injured _________________________    Date of Birth ______________________________

Address ________________________________________________ Phone __________________________

        ________________________________________________

Name of Parent(s) / Guardian(s) _________________________________________________________

Contact number for Parents ____________________________ Daytime  ________________ Evening

Date of Injury ________________________________________ Time of Injury __________________

Location of Incident ____________________________________________________________________

Describe Injury -





Describe Treatment Provided (if any) -
(also note if transported for medical attention - provide location and name of Doctor)





The following information should be found on the injured party's AUTHORIZATION TO 
TREAT (player registration form). Please fill in ALL information.

Primary Medical Insurance Company _____________________________________________________

Policy / Group Number _________________________________________________________________

Name of Primary Insured _______________________________________________________________

Parent Informed of Injury -  YES / NO   

Date and time of Notification _________________________________________________________

Safety Coordinator Informed of Injury -  YES / NO
---------------------------------------------------------------------------------------

Call Peggi Alegrete (Adult Reg. & Safety person) with questions or serious injury.
(408) 781-2356
email: peggi.alegrete@kyocera.com

Return report to Snack Shack at Bagby Fields