Witness Statement - Injury / Accident Report
Gymnastics NSW
If a witness is a child under the age of 18, parent / guardian details must be provided.
Report File Number
Unique number on top of Injury / Accident Report
Name of injured person
First Name
Last Name
Date when injury occurred
/
Day
/
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Gymsport injured person was primarily involved with at time of injury:
Please Select
Acrobatics
Aerobics
FreeG
GfA
Men's Artistic
Rhythmic
TeamGym
Trampoline
Women's Artistic
Witness
First Name
Last Name
Witness's Role / Position
e.g. athlete, athlete's coach, coach, official, judge, etc.
Is the Witness under 18?
Yes
No
Witness Phone Number
Please enter a valid phone number. For a witness under the age of 18, please provide Parent / Guardian details.
Format: 0000 000 000.
Witness's Parent/Guardian Phone Number
Please enter a valid phone number. For a witness under the age of 18, please provide Parent / Guardian details.
Format: 0000 000 000.
Witness Email
example@example.com; For a witness under the age of 18, please provide Parent / Guardian details.
Witness's Parent/Guardian Email
example@example.com; For a witness under the age of 18, please provide Parent / Guardian details.
Witness Statement
Describe what happened. Use the full name of all people involved.
Files, photo and document uploads:
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of
Witness Signature
Date
/
Day
/
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
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Submit
Should be Empty: