WHEN, WHERE, WHY AND HOW IT HAPPENED

CLUB ACCIDENT REPORT

STATE:         SOUTH CAROLINA         

ASSOCIATION/ FEDERATION: SOUTH CAROLINA SQUARE & ROUND DANCE FEDERATION

CLUB:______________________________DATE OF ACCIDENT:____________________

CLUB OFFICER:______________________________TELEPHONE:___________________

LOCATION OF ACCIDENT:___________________________________________________

NAME OF PERSON INJURED:_________________________________________________

ADDRESS:__________________________________________________________________

NATURE OF INJURY:________________________________________________________

DESCRIPTION OF ACCIDENT:________________________________________________

_________________________________________________________________________

_________________________________________________________________________

WHEN AND WHERE WAS TREATMENT GIVEN:________________________________

_________________________________________________________________________

NAME AND ADDRESS OF WITNESSES:
1._________________________________________________________________________

2._________________________________________________________________________

3._________________________________________________________________________

SIGNED:________________________________________

TELEPHONE:____________________________________

PLEASE COMPLETE FORM WITHIN 48 HOURS OF ACCIDENT AND SEND TO:
John and Rosilyn Earley
9422 Plowden Mill Road
Alcolu, S.C. 29001
UPON RECEIPT OF THIS ACCIDENT REPORT A CLAIM FORM WILL BE MAILED TO THE CLUB.