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INCIDENT DATE:
TIME:
AM
PM
INJURED PERSON:
Club Member
Non-Member Participant
Other:
INJURY
INFORMATION
Injured Person’s Full Name (Last/First/Middle):
Male
Female
If injured person is a minor, Parent/Guardian Name:
Address:
City:
State:
Zip:
Phone:
-
Date of Birth:
Social Security Number:
Was injured wearing a helmet at the time of the accident?
Yes
No
N/A
Describe the person’s injury and what part of the body was injured:
.
Disposition:
Refused care
First aid only
Referred to:
Attended by EMS
Transported by:
, to:
Continued riding
Minor released to parent
ACCIDENT
INFORMATION
Where was the location of the incident,
provide street name and nearest intersection:
Describe how the incident occurred:
WITNESS
INFORMATION
1. Name:
Phone:
-
Address:
City:
State:
Zip:
2. Name:
Phone:
-
Address:
City:
State:
Zip:
3. Name:
Phone:
-
Address:
City:
State:
Zip:
AUTOMOBILE
INFORMATION
PERSON DRIVING THE AUTO:
Name:
Phone:
-
Address:
City:
State:
Zip:
OWNER OF THE AUTO:
Name:
Phone:
-
Address:
City:
State:
Zip:
Make/Model/Year of auto:
Insurance company:
Name:
Phone:
-
1. Passenger Name:
Phone:
-
2. Passenger Name:
Phone:
-
3. Passenger Name:
Phone:
-
POLICE
INFORMATION
If called, name of police
department that investigated accident:
Officer's Name:
Phone:
-
Accident report number:
PROPERTY
DAMAGE
(other than auto accidents)
Description of property:
Description of Damage:
Owner’s Name:
Phone:
-
Owner’s Address:
City:
State:
Zip:
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