Accident Report Form

First name of injured person

Last name of injured person

Date of Birth

Day

Month

Year

Gender

Phone Number for injured person

Location of accident

Date and time of accident

Day

Month

Year

Time

HoursMinutes

Name of individual(s) who dealt with the accident:

Details of injury:

Did anyone witness the accident

YES

If YES for witness, Who?

Contact Number of Witness

Details leading up to the accident / how it happened:

Emergency Services Contacted

YES

Details of events after the accident:

Details of treatment given:

Please state by who?

Named Emergency Person Contacted

YES

Emergency person includes Parent / Carer. Any form of head injury MUST be contacted. Details can be found on LoveAdmin Register under 'Fixtures & Calendar'

If YES, contacted by whom and when?

Name of Coach / First Aider

Signature

Signature field is empty.