Ogden Curling Club, throw some stones in our houses.

Digital Copy Accident Form

Accident Form

Release Form Agreement

Club Name

Facility Name:

Facility Address:

Facility Phone #:

Accident Occurred During

Date of Accident:

Time of Accident:

Name of Injured: (First and Last)

Club Affiliation:

Member

Guest

Student

Injured Address:

Injured Phone#:

Injured Email:

Date of Birth

Age:

Signed Waiver

Yes

No

Describe injury in detail (e.g. open wound, sprain, strain, fracture, etc.)

How did accident occur?

Describe First Aid rendered?:

Who rendered First Aid?

Was the injured party taken to hospital?

Yes

No

By Whom:

How did the injured party leave the facility?

Will or has the injury required surgery?

Yes

No

Don't know

Witness Name (First and Last):

Witness Address:

Witness Phone Number

Witness Email Address

Name of Person Completing Form (First and Last):

Role of person Completing Form

Phone Number

Email (Person Completing the Form)

Opt-In

By checking, I agree this the form is correct to the best of my abilities

Free Text

Once the Form has been submited. This form well be kept in the Club Records (7 Years) and to prodcue should a claim or lawsuit be filed regarding this incident.

Release Form Agreement

Ogden Curling Club

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