INSTRUCTIONS FOR FILLING OUT

CLUB ACCIDENT REPORT

(Club officer filling out form)

1.    Enter the name of your Affiliate. DO NOT use abbreviations.

2.    Enter the full name of the club.

3.    Enter the date of the accident.

4.    Enter your name. Do not use nicknames.

5.    Enter your telephone number.

6.    Enter the name of facility; room, etc., providing as much detail as possible.

7.    Enter the full name of the person injured including address, telephone number, club name, and Association.

8.    Enter the nature of the injury to the best of your knowledge.

9.    Enter a description of the accident in as much detail as possible using the memory of any witnesses.

10.Enter information on when and where treatment was given. If the injured person did not want treatment, indicate this as well.

11.Enter the full name and address of any witnesses.

12.Sign and, at a minimum provide a telephone number.

Submit three copies of the form by mail ASAP. Keep a copy for your records.

August 2008