GRAND TRAVERSE BAY YMCA NOTICE OF ACCIDENT / INCIDENT

Please fill this form out completely for accident / incident.

Initialed By: _______________ Date: _______________

Name: __________________________________________ Member: __________ Non-Member: __________

Address: __________________________________ City: _____________________ Zip: _____________

Phone: _(____)____________________(____)____________________ Date of Birth: ___________________

Date Occurred: _______________________________ Time Occurred: ______________________________

Type of Injury/Incident: ____________________________________________________________________

Attended By: __________________________________________ Physician / Police Called: ____________

Family Member Contacted: _____________________ Condition of Premises: __________________

Location of Accident/Incident: _______________________________________________________

YMCA Staff Person(s) on Duty: ______________________________________________________________

Others Involved: ___________________________________________________________________________

Witnesses Home Work

Name: _____________________________________ Phone: _(____)_______________(____)______________

_____________________________________ Phone: _(____)_______________(____)______________

_____________________________________ Phone: _(____)_______________(____)______________

Describe Exactly What Occurred: _____________________________________________________________

____________________________________________________________________________________________

____________________________________________________________________________________________

Describe What Was Done: __________________________________________________________

________________________________________________________________________________

Follow-Up: _________________________________________________________________________________

Please Print and fax this form to Barb Beckett at 231.947-0651