Name of Club:
Horrabridge Rangers Sports Association
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1. |
Site where accident
took place |
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2. |
Name of person in
charge of session/competition |
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3. |
Name of injured
person |
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4. |
Address of injured
person |
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5. |
Date and time of
incident/accident |
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6. |
Nature of
incident/accident |
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7. |
Give details
of how and precisely where the accident took place. Describe what activity
was taking place e.g. training programme, getting changed, etc. |
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8. |
Give full details of
the action taken including any first aid treatment and the name(s) of the |
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9. |
Were any of
the following contacted? |
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Police |
Yes |
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No |
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Ambulance |
Yes |
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No |
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Parent/Guardian |
Yes |
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No |
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10. |
What happened
to the injured person following the accident? (e.g. went home,
went to hospital, carried on with session) |
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11. |
All of the
above facts are a true and accurate record of the incident/accident. |
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Signed |
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(on behalf on Horrabridge
Rangers Sports Association) |
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Name (please print) |
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Date |
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Please return to the
Club Secretary