Accident Report

Accident Report
Sport Club*
Accident Date and Time*

MonthDayYear
DateHourMinutesAM/PM Option
Person Completing Report*

First NameLast Name
Name of Injured Person*

First NameLast Name
ID# of Injured Person*
Gender Identity of Injured Person*
Local Address of Injured Person*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Local Phone Number of Injured Person

Area CodePhone Number
Local Cell Phone Number of Injured Person*

Area CodePhone Number
Email of Injured Person*
example@example.com
Status of Injured Person*

StudentStaffFacultyGuestOther

Accident Report
Type of First Aid Administered*
First Aid Administered by*
Immediate Action Taken
Police Called?*

YesNo
Officer's Name
Ambulance Called?*

YesNo
Sent to Health Services?*

YesNo
Sent to Hospital*

YesNo
Method of Transportation
Method of Transportation*
Time ambulance arrived

:HourMinutesAM/PM Option
Time private vehicle left

:HourMinutesAM/PM Option
Time police arrived

:HourMinutesAM/PM Option
Care of injured person transferred to
Name

First NameLast Name
Position

Accident Report
Injured person's Signature*

Clear
Date*

MonthDayYear
Date
Name of Witness #1*

First NameLast Name
Address of Witness #1

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number of Witness #1*

Area CodePhone Number
Email Address of Witness #1*
example@example.com
Name of Witness #2*

First NameLast Name
Address of Witness #2

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number of Witness #2*

Area CodePhone Number
Email Address of Witness #2*
example@example.com

Accident Report
Medical Release Form
Date and Time*

MonthDayYear
DateHourMinutesAM/PM Option
Staff member* has advised me,Participant*to seek medical attention at the University Health Service or personal physician due to my * while at the .
Please describe Other
My signature on this document indicates my understanding of the advice to seek medical attention.
Participant's Name*

First NameLast Name
Participant's Phone Number*

Area CodePhone Number
Participant's Signature*

Clear
Date*

MonthDayYear
Date
Participant's ID Number*
Witness Name*

First NameLast Name
Witness Signature*

Clear
Date*

MonthDayYear
Date
Club Officer's Name*

First NameLast Name
Club Officer's Signature*

Clear
Date*

MonthDayYear
Date
Student Supervisor Name*

First NameLast Name
Student Supervisor Signature*

Clear
Date*

MonthDayYear
Date
Please list any other important details below
Should be Empty: