Grievance Form

Instructions: Please type or print legibly in black ink. You may wish to keep a photocopy of this form for your own records. If available, please enclose a copy of any supporting documents to assist with a quick resolution to the matter.

Person Filing Complaint
Name:      
Club/Team:   Street Address:  
City:   Zip Code:  
Home Telephone:   Alternate Telephone:  
Email address:      

Complaint Filed Against
Name:      
Club/Team:   Street Address:  
City:   Zip Code:  
Home Telephone:   Alternate Telephone:  
Email address:      

Rules Violated
Club, UYSA and/or US Club rules e.g. UYSA II.F.4.a

Incident Description

Please describe the incident (including date, time, place where it occurred): If possible, include the names of those involved and any witnesses. If you already have a letter or other written statement that includes this information, you may simply attach it (please state below). You may continue description on the back of form if needed. Send to: CompDirector@impactunited.com