NSW Futsal Send Off Report

Referees and Administrators please keep a copy of this report for your own records.

Date of incident

Enter the date when the incident occurred

Your Name *

First

Last

Enter your name

Phone

Optional. Enter your phone number so we can contact you.

Email *

Enter an email address we can use to contact you

Competition

Enter the competition and age group as applicable

Venue

Enter the name of the venue where the incident occurred

Player name

Enter the name of the offending player

code Name Email

Team name

Enter the team name of the offending player

Opponent team name

Enter the opponent team name

Administrator Name

Enter the name of the administrator on duty at the venue.

Send off code *

• Two Caution Offences
• Denies Goal Scoring Opportunity
• Serious Foul Play
• Foul or Abusive Language
• Offences Against the Sport
• Violent/Dangerous Striking
• Fighting
• Violent/Dangerous Charging
• Blow to the Head
• Blow to the Mid Body
• Violent/Dangerous Slide Tackle
• Head Butting
• Threatening Games Official
• Physical Attack on Games Official
• Attacking Spectators
• Attempting to Strike Official with Ball or other object.
• Pushing Officials or Spectators with Open Hand or Shoulder
• Other – Please specify below in “Details of Send Off” section

Please select the reason for the sending off

Details of the offence and dismissal

Please provide as much information as possible on the incident

Submit