ACCIDENT REPORT No.

Date:□ Other (please state)

Injured Person: Name:

□ Male                         □ Female                          Date of Birth:                   Phone:                          Email:

Address:

□ Athlete                     □ Coach                            □ Spectator                     □ Volunteer (state role)

Parent / Guardian (If injured person is a minor - Under 16) Name:

□ Male                         □ Female                           Phone:                             Email:                              Address:

Accident/Incident Information

Name of Event where incident occurred:Event Address / Location: Specific Location of incident:

Classification:            □Non-Injury                     □ Minor Injury                 □ Serious Injury Describe the injury and how it occurred (use a separate sheet if necessary):

Disposition:                 No care given: □              Patient refused □         Not required

Released:                    □ To parent                      □ To personal vehicle    □ To other: Referral:          □ To doctor                 □ To hospital/clinic              □ Not required

Ambulance:                □ Required                      □ Patient requested

Witness Information Name:                             □ Not required                    Phone:                    Email:                           Position:

Person completing this report:

I declare that to the best of my knowledge, the information provided in this report is true and correct.

Name:

Phone:                        Email:                             Position:                      Signature:

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