Rainhill United JFC - Incident / Accident Report Form

Rainhill United Football Club

Incident / Accident Report Form
Anything written on this form will be held in strict confidence. As a club, we need to know these details in order to meet the specific needs of your child and to meet necessary FA Safeguarding criteria
Incident / Accident Information
Date and time of accident:*

DayMonthYear
DateHourMinutes
Place where accident took place:*
Name of injured person:*

First NameLast Name
Gender:*

MaleFemale
Address of injured person:*

Street Address

Street Address Line 2

CityCounty

Postcode
Name of manager in charge of match / training session:*
Nature of incident / accident:*
Give details of how and precisely where the incident or accident took place (Describe what activity was taking place, i.e. training session, getting changed etc):*
Give full details of the action taken including any first aid treatment and the name(s) of the First Aider(s):*
Were any of the following contacted:
Police*

YesNo
Ambulance*

YesNo
Parent / Guardian*

YesNo
Other*

YesNo
What further action was taken? (i.e. taken home / taken to hospital):*
Confirmation

BY AGREEING ABOVE AND SUBMITTING THIS FORM, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT IS EQUIVALENT TO AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Please confirm that all of the above facts are a true and accurate account of the incident / accident:
Signature:

Clear
Print Name:*
Electronic Signature:*

I agree with the information above to be submitted
Today's Date:*

DayMonthYear
Submitter Email:*
example@example.com
Should be Empty:

Incident / Accident Information