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Fill and Sign the Mary Kay Order Form

Fill and Sign the Mary Kay Order Form

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CONEY HILL RFC - INCIDENT/ACCIDENT REPORT FORM Site where incident/accident took place: Name of person in charge of session/competition: Name of injured person: Address of injured person: Date and time of incident/accident: What was the type of Injury (e.g. Head, limb, Neck etc…) Give details of how and precisely where the incident/accident took place. Describe what activity was taking place, e.g. training game, getting changed, etc. (continue on a separate piece of paper as necessary) Give full details of the action taken including any first aid treatment and the name(s) of the first aider(s) (continue on a separate piece of paper as necessary) : Were any of the following contacted: Police: Ambulance: Parent/carer: Yes ¨ No ¨ Yes ¨ No ¨ Yes ¨ No ¨ What happened to the injured person following the incident/ accident? (e.g. went home, went to hospital, carried on with session) All of the above facts are a true and accurate record of the incident/accident. SIGNED: DATE: Name: Position ______ ____________ PDF created with pdfFactory trial version www.pdffactory.com

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