Please complete this Incident/Accident Report form within ...
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Diocese of Metuchen Office of Youth & Young Adult Ministry CYM Basketball League – 2016/2017Season Incident/ Accident Report Date of Incident / Accident: ____________________________ Time:______________ __________________ Where specifically did the incident/ accident occur? _________________________________________________________________ ____________________________________________________________________________________________________________ Name of Person(s) Involved: ____________________________________________________________________________________ Address: ____________________________________________________________________________________________________ Phone Number: (_______) ________ - ___________________ Sex: M __ F __ Date of Birth/ Age: ____________________ Parent/Guardian Name: ________________________________________________________________________________________ Address: ____________________________________________________________________________________________________ Phone Number: (_______) ________ - ___________________ Was Parent/ Guardian Notified: Y__ N __ If so, please list when Parent/Guardian was notified and by whom: ____________________________________________________________________________________________________________ Describe Incident/ Accident in Detail: _____________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ Was First Aid Given? Y ____ N ______ If so, describe First Aid procedure in detail: ____________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ Who provided the first aid? (Name, Address and Phone Number): ______________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ Were Police notified? Y__ N__ If yes: Responding Officer’s Name: _______________________________________________ Department/Township: ____________________________________________________ Was an Ambulance Called to the Scene? Y__ N__ If yes: Name of Ambulance Company? ________________________________ If applicable which hospital was person(s) involved taken to? __________________________________________________________ ____________________________________________________________________________________________________________ Was medical attention refused by Injured Party/Parent/Guardian? Y__ N__ Please list the names of all employees/coaches/volunteers present: ______________________________________________________ ____________________________________________________________________________________________________________ Report Prepared By: __________________________________________________________________________________________ Signature: ______________________________________________________ Date: _____________________________________ Reviewed By: ___________________________________________________ Date: _____________________________________ Please complete this Incident/Accident Report form within 24 hours of Incident/Accident NOTE: Bollinger Insurance Form MUST be handed to parent immediately upon submission of Incident Report return to Rev. Edmund Luciano - Director Office of Youth & Young Adult Ministry PO Box 191 Metuchen, NJ 08840-0191
Transcript of Please complete this Incident/Accident Report form within ...
Diocese of Metuchen
Office of Youth & Young Adult Ministry
CYM Basketball League – 2016/2017Season
Incident/ Accident Report Date of Incident / Accident: ____________________________ Time:______________ __________________ Where specifically did the incident/ accident occur? _________________________________________________________________
____________________________________________________________________________________________________________ Name of Person(s) Involved: ____________________________________________________________________________________ Address: ____________________________________________________________________________________________________ Phone Number: (_______) ________ - ___________________ Sex: M __ F __ Date of Birth/ Age: ____________________ Parent/Guardian Name: ________________________________________________________________________________________ Address: ____________________________________________________________________________________________________ Phone Number: (_______) ________ - ___________________ Was Parent/ Guardian Notified: Y__ N __ If so, please list when Parent/Guardian was notified and by whom:
____________________________________________________________________________________________________________ Describe Incident/ Accident in Detail: _____________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________ Was First Aid Given? Y ____ N ______ If so, describe First Aid procedure in detail: ____________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________ Who provided the first aid? (Name, Address and Phone Number): ______________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________ Were Police notified? Y__ N__ If yes: Responding Officer’s Name: _______________________________________________
Department/Township: ____________________________________________________ Was an Ambulance Called to the Scene? Y__ N__ If yes: Name of Ambulance Company? ________________________________ If applicable which hospital was person(s) involved taken to? __________________________________________________________
____________________________________________________________________________________________________________ Was medical attention refused by Injured Party/Parent/Guardian? Y__ N__
Please list the names of all employees/coaches/volunteers present: ______________________________________________________
____________________________________________________________________________________________________________
Report Prepared By: __________________________________________________________________________________________
Signature: ______________________________________________________ Date: _____________________________________
Reviewed By: ___________________________________________________ Date: _____________________________________
Please complete this Incident/Accident Report form within 24 hours of Incident/Accident
NOTE: Bollinger Insurance Form MUST be handed to parent immediately upon submission
of Incident Report return to
Rev. Edmund Luciano - Director Office of Youth & Young Adult Ministry
PO Box 191 Metuchen, NJ 08840-0191
