Aquatics for All

IMPORTANT: If you have had an accident then please fill in this form as soon as possible. Where you believe the accident or incident might potentially lead to an insurance claim, please also notify the Head Coach and a member of the committee.

Do not admit liability, do not make an offer or promise to pay.

Place/pool session where the incident occured:

Date of the incident:

YYYY

Time of the incident:

Hour

Minute

Second

Circumstances:

Please provide details of any implied or actual threat of legal action arising out of this incident:

Injured Person's Name

First Name

Last Name

Injured Person's Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Injured Person's Age

Incident Witness 1 Name, Address & Contact Details:

Incident Witness 2 Name, Address & Contact Details:

Incident Witness 3 Name, Address & Contact Details:

Was any property damaged in this incident?

If yes please provide details of the property, it's address or location and details of the damage:

Please provide any additional information which may be relevant:

Reporting Person's Name

First Name

Last Name

Reporting Person's Address and Contact Details:

Reporting Person's Position in the Club

I agree that the information I have submitted on this form is true to the extent of my knowledge

Yes, I agree