1. Site where incident/accident took place:..................................................................................... .....................................................................................................................................................

2. Name of person in charge of session/competition:.....................................................................

3. Name of injured person:..............................................................................................................

4. Address of injured person:........................................................................................................... ..................................................................................................................................................... .....................................................................................................................................................

5. Date and time of incident/accident:.............................................................................................

6. Nature of incident/accident: ........................................................................................................

....................................................................................................

7. Give details of how and precisely where the incident/accident took place. Describe what activity was taking place, eg training game, getting changed, etc. ..................................................................................................................................................... ..................................................................................................................................................... .....................................................................................................................................................

8. Give full details of the action taken including any first aid treatment and the name(s) of the first aider(s): ..................................................................................................................................................... ..................................................................................................................................................... .....................................................................................................................................................

9. Were any of the following contacted:

Police: Yes / No

Ambulance: Yes / No

Parent: Yes / No

10. What happened to the injured person following the incident/accident? (eg went home, went to hospital, carried on with session) ..................................................................................................................................................... ..................................................................................................................................................... ..................................................................................................................................................... .....................................................................................................................................................

11. All of the above facts are a true and accurate record of the incident/accident.

Signed: ........................................................................................................................................

Name: ..........................................................................................................................................

Position:.....................................................................................................................................

Date: ............................................................................................................................................

This form should be retained by the Club and submitted to BARLA/RFL on request.