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Fill and Sign the Missing Receipt Declaration Berea College Berea Form

Fill and Sign the Missing Receipt Declaration Berea College Berea Form

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STUDENT ACCIDENT REPORT FORM Name and address of parish: Name of person injured: Parent’s name: Address: Date of accident: Time: AM / PM Coach or person supervising: Describe how accident occurred: Condition of premises: Extent of injury: Measures taken after accident: Was First Aid administered? Yes / No Were parents notified? Yes/No How? By whom? By whom? At what time? Witnesses and their addresses: Student accident insurance? Yes/No Insurance Company: Name of person making report: Position: Date of report: ALL ACCIDENTS SHOULD BE REPORTED TO THE PASTOR/PRINCIPAL’S OFFICE ON THIS FORM THE DAY THEY OCCUR. Please forward copy to: Gallagher Bassett Services P.O. Box 687 Southfield, MI 48037-0687 Telephone: (248) 352-1062

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