Fairfax County Neighborhood and Community Services
Athletic Services Division
12011 Government Center Parkway, Suite 1050
Fairfax, Virginia 22035-1115
Fax -703-324-5546
athleticservices@fairfaxcounty.gov
Location of Accident: ____________________________________ Date of Accident: _______________________
Full name of injured person: _________________________________________________________________________
Address: __________________________________________________________________________________________
Telephone number: _______________________ Sex: ______ Time of Accident: _______________________
Accident Reported By __________________________ To: ________________________________________________
(Person and/or organization)
Date: _____________________ Time:________ Check: In person:________ By phone__________________
Injured person was treated by ____________________________________________________________and/or taken
To: __________________________________________ By:
_________________________________________________
(Address of hospital, doctor, home, etc.) (Person and/or organization)
Name of insurance company:__________________________________Notified: Yes ________ No________
Policy Number: __________________________________________
Describe in detail the extent of the injuries:_____________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Explain fully what care was given and what procedure was followed: _______________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Describe where and how the accident occurred: _________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Name of person supervising activity:_______________________ Position:_______________________________
Witness: Name Address Telephone Number
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
THIS REPORT IS TO BE FILED WITH NEIGHBORHOOD AND COMMUINTY SERVICES IMMEDIATELY
ON THE DAY OF THE ACCIDENT. Please mail, email, or fax this form.
Date_______________________________ Signature_________________________________________________
(NCS