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Signature of member injured
to indicate agreement with information given above
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Signature of Instructor/Group Leader
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Accident / Incident Report Form
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Please telephone the CHSG Secretary as soon as possible to notify details of the incident
using the telephone number published in the current edition of the Newsletter, available online to all members
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This notification of accident/incident will be electronically sent to the CHSG Secretary upon submission,
as completed by the appropriate Instructor/Group Leader
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This form submission will be reviewed at the next Trustees meeting
to ascertain any actions necessary
Person Injured
Accident Date/Time
If you have answered yes to any of the questions above you are strongly recommended to seek medical advice before using gym facilities.
Emergency Contact Details
Accident Details
Witnesses
Anchor 1
**Signature(s) missing**
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