GCB Senior Injury/Incident Report Form

GCB Senior Injury/Incident Report Form
Last Name*
Name*
Email
example@example.com
Phone Number*
Format: 0000 000 000.
Parent/Guardian/Emergency Contact Name
Parent/Guardian/Emergency Contact Email
example@example.com
Parent/Guardian/Emergency Contact Phone
Format: 0000 000 000.
Date incident occured*

MonthDayYear
Date
Time of Incident

Hour Minutes

AM/PM Option
Reported to*
Date Reported*

MonthDayYear
Date
Time reported

Hour Minutes

AM/PM Option
Competition
Team*
Opposition*
InjuryTheftLost/foundEvacuationUnauthorised entryCleaning/maintenanceSafety hazerd/near missFireProperty DamageType of inciden
Property Damage
GCSLC - 296 Nerang-BroadBeach Rd Carrara, QLD, 4211Talle - 1525 Gold Coast Hwy, Palm Beach, QLD, 4221Info
What happened?
Injury - what part of the body did you injure and how?
Part of the Body Affected
NoneSelfFirst AideDoctorHospitalAmbulanceIceOther
AmbulanceSelf TransportAmbulance Time Arrived
Time Ambulance arrived:

Hour Minutes

AM/PM Option
Hospital Taken To
Self Transport
Time Ambulance left:

Hour Minutes

AM/PM Option
Self Transport Waiver
I ____________________________ will be transporting __________________________________________to hospital/home. I agree that Gold Coast Basketball will not be held liable for complications that happen once leaving the court area.
Should be Empty: