Group details

Name of group_________________________________________________________________________

Name of group leader___________________________________________________________________

Names of others present_________________________________________________________________

Accident details

Date and time of accident/incident_________________________________________________________

Name of person involved_________________________________________________________________

Date of birth of person involved___________________________________________________________

Emergency contact details for the person involved (usually parent/guardian)

Name________________________________________________________________________________

Telephone number______________________________________________________________________

Please describe the accident/incident that occurred (continue on separate sheet if necessary).

_____________________________________________________________________________________

_____________________________________________________________________________________

Action taken during and following the accident incident.

_____________________________________________________________________________________

_____________________________________________________________________________________

People contacted (include dates and times)

If medical attention was required, please note the name and address of the medical facility and the people who treated the person involved in the accident/incident.

_____________________________________________________________________________________

_____________________________________________________________________________________

Please detail any follow-up action required.

_____________________________________________________________________________________

_____________________________________________________________________________________

Name of person completing this form (print name)____________________________________________

Signed__________________________________________ Date________________________