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
2 digit month, 2 digit day, 4 digit yearDate
Time of Incident

Hour Minutes

AM/PM Option
Reported to
Date Reported

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Time reported

Hour Minutes

AM/PM Option
Competition
Team
Opposition
2. Type of Incident
Property Damage
Location of the Incident
What happened?
Injury - what part of the body did you injure and how?
Part of the Body Affected
Treatment required

Other
Transport to Hospital
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: