| Type of Incident: | Other — Do not use if a team, player, coach, or spectator is involved. Use only if the incident cannot be classified as any other Type of Incident above. |
| Match Number: | 650 |
| Date of Incident: | 2016-09-18 |
| Time of Incident: | 10:00:00 |
| Location of Incident: | York school |
| Competition: | 2016_SOR_FALL_ |
| Home Team: | PAC San Jose |
| Visiting Team: | Jason Perez |
| Age Group and Gender: | U17B |
| Team Affiliation of Individual Committing Incident: | Jason Perez |
| Incident Summary: | Description of incident self-reported by PAC SJ. |
| Comments: | No action taken. Thanks for informing the PAD Committee. |
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