St. Columba's Church Hall, Plas Newton, Chester, Cheshire, CH2 1SA, Tel: 01244 535788

Registered Charity 1123789

 Signature of member injured

to indicate agreement with information given above 

 Signature of Instructor/Group Leader 

Signatures?

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 Accident / Incident Report Form 

 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

Newlsetter - Click here

This notification of accident/incident will be electronically sent to the CHSG Secretary upon submission,

as completed by the appropriate Instructor/Group Leader 

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