Accident Form

We’re sorry that you’ve had a bad experience. Please use this form to report any accident or incident which occured at St Philip’s Church Centre. By completing the form you agree to us contacting you if necessary and storing your details.

Name of person who had the accident(Required)

First Last

Age if under 18

Reason for being on the premises (e.g. attending a class, eating in the cafe, at a church service) and please mention the group involved (e.g. Alpha Group)(Required)

Address of person who had the accident(Required)

Street Address Address Line 2 City ZIP / Postal Code

Phone number of person who had the accident(Required)

Email of person who had the accident(Required)

Short description of accident: What happened? In a few words only(Required)

Date of accident(Required)

Time of accident(Required)

Where did the accident happen?(Required)

Describe in more detail what happened, including any cause if known(Required)

Details of injury and any action taken (first aid given, ambulance called, etc.)(Required)

Recommendations to prevent similar accidents happening in the future

Is somebody else reporting the accident?(Required)

Name of person reporting

First Last

Address of person reporting

Street Address Address Line 2 City ZIP / Postal Code

Phone of person reporting

Email of person reporting

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