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