| Type of Incident: | Injury |
| Match Number: | |
| Date of Incident: | 2012-09-08 |
| Time of Incident: | 04:50:00 |
| Location of Incident: | Burlingame High School Soccer Field |
| Competition: | 2012_SOR_NPL_ |
| Home Team: | Burlingame Ajax |
| Visiting Team: | Palo Alto White |
| Age Group and Gender: | U17B |
| Team Affiliation of Individual Committing Incident: | |
| Incident Summary: | Injury to Burlingame player |
| Comments: | |
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