Heygarth United Football Club

Location of incident/accident:

Name of person in charge of session/competition:

Name of injured person:

Address……………………………………………………………………………………………………………………………………………………………………………Postcode………………………………………………………………………………

Telephone………………………………………………………………………………

Date /Time of Incident/Accident:

Give Details of how precisely where the accident took place

Give Full Details of actions taken:

Where any of the following contacted:

Police                          

Ambulance

Parent/guardian

What happened to the injured person following the accident?

Declaration

All of the above facts are a true and accurate record of the incident/accident

Signed…………………………………..Name(Print)…………………………….

Date………………………………