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GNCC Curling Accident Form
Please have a club member complete this form when an accident occurs in your club that requires medical attention other than basic first aid. Also please contact the
GNCC chair
.
NOTE: This is NOT a claim form. This information will be used to complete a claim form if one is required.
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* Indicates required question
Details of Accident
Accident occurred during?
*
League
Training Session (Open House, Learn to Curl class)
Bonspiel
Playdown or Championship Event
Other:
Date of Accident
*
MM
/
DD
/
YYYY
Time of Accident
Time
:
AM
PM
Facility Name and Address
*
Your answer
Describe how the accident occurred and what body areas appeared to be injured
*
Your answer
Was first aid administered and if so, by whom?
*
Your answer
How did the injured person leave the facility, and did they go to a hospital, if so which one?
*
Your answer
List any witnesses
Your answer
Contact Information of Injured
Injured persons Name
*
Your answer
Injured persons Age
*
Your answer
Injured persons Address
*
Your answer
Injured persons Email
*
Your answer
Injured persons Phone
*
Your answer
Injured persons Curling Club affiliation, if any
Your answer
Follow-up Information
Someone should contact the injured person to see how they are doing. If possible, describe their current condition.
*
Your answer
Person completing this form contact information
Name of the person completing this form
*
Your answer
Title
*
Your answer
Email
*
Your answer
Phone Number
*
Your answer
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