Section 1 of 3
DECLARATION D'ACCIDENT
Ce formulaire est destiné aux membres qui ont eu un accident
1. Remplir le formulaire ci-dessous. Il arrivera directement chez moi
2. Me transmettre le certificat médical (Annexe D) ICI
3. Me transmettre l'attestation mutuelle en y collant une vignette (Annexe C) ICI
Ces deux annexes doivent me parvenir via mon adresse mail : secretaire@volleygembloux.be
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Section 2 of 3
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Verstraelen Jason
Verstraelen Jason
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19 janvier 2007
19 janvier 2007
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450553979
450553979
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Rue du saucy 17 5031 Grand-Leez
Rue du saucy 17 5031 Grand-Leez
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morainemagali@live.be
morainemagali@live.be
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0468 36 35 42
0468 36 35 42
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13/09/2025
13/09/2025
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16h
16h
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Le joueur est retombé sur le pied de l adversaire et sa cheville a fait 90 degré au sol
Le joueur est retombé sur le pied de l adversaire et sa cheville a fait 90 degré au sol
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Déchirure ligaments fissures à l'os du talon
Déchirure ligaments fissures à l'os du talon
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Etes-vous titulaire de votre mutuelle ?
Etes-vous titulaire de votre mutuelle ?
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Section 3 of 3
Titulaire de la mutuelle
Si vous n'êtes pas titulaire de votre propre mutuelle, veuillez compléter la suite...
Verstraelen Jean-Michel
Verstraelen Jean-Michel
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Adresse complète si différente de l'accidenté
Adresse complète si différente de l'accidenté
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morainemagali@live.be
morainemagali@live.be
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0468 36 35 42
0468 36 35 42
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