Existing Injury Form

Please complete this form to the best of your knowledge for your child's existing injury.

Member's full name *

Member's date of birth *

Name of person completing form *

Email *

Enter your email

By adding your email here you will receive a copy of the form for your records

Date injury occurred *

Time injury occurred *

Who was present when injury occurred

Detailed description of how injury occurred *

Detailed description of injury *

including where on body, and size of injury

Was medical treatment sought? *

Yes

If so where from and what was the outcome? *

When was the injury reported to setting? *

Before session

Noticed by staff during session