Accident Report

(626) 502-1547
info@nbcfc.org

ACCIDENT REPORT

When an accident occurs on the premises or anywhere that New
Beginning is held responsible:
Fill out the following Accident Report form and submit to the Clerk.

Date & Time of accident/incident*

Where did the accident/incident occur?*

Briefly describe the circumstances of the accident/incident.*

Name of injured person*

Email of injured person*

Phone of injured person

Address of injured person*

Injury and part of body injured*

Date of Birth*

Member or Guest*

Waiver: I do not wish to receive medical attention*

1st Witness Name

1st Witness Phone

1st Witness Email

1st Witness comments related to incident

Other name and contact details of all witnesses:

Initial action to prevent reoccurrence*

Name of person completing form*

Phone of person completing form*

Email of person completing form*