Date of Match

Game Location

Game Age Group & Type

First Half/Second Half

First HalfSecond Half

Time in Half

Reported By Name

Reporter Email

Opposition Club involved

Ground Manager Name

Name of Accused

Other Player/Person Involved

Incident Description

If you require more text space please email attachment or document directly to club.After submission

Type of Offence (If there is more than 1 relevant offence include offense number in incident description)

1) Use offensive or obscene language to any participant. 2) Enter the Field of Play or the Playing Area during the course of a match without the prior approval of the Ground Manager appointed by the home Club and/or League.3) Excessively dispute the decision of a Referee or Touch Judge either during or after a match.4) Assault, or act with aggression, to any person/s5) Behave in a way contrary to the Code of Conduct and/or the spirit of the game6) Behave in a way which disturbs the enjoyment of a match, function, activity or event by any person/s, or brings discredit to any Club, League or the game.7) Act in such a way as to exhibit racial intolerance, by language or other conduct, to any person/s8) Refuse to accept the reasonable direction of the Ground Manager, official of the team/ Club which that person is supporting, or official of the home Club and/or League.

I recommend this charge be graded as

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Agree to provide Evidence

YesNo

By submitting this online dismissal form, I understand and agree by selecting Yes or No above, that I may be required to provide evidence at a NSWRL Regional Group Judiciary Tribunal.

Ground Incident Report

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