LGBT Masters Aquatics Club

IMPORTANT: If you have had an accident then please fill in this form as soon as possible. Where you believe the accident or incident might potentially lead to an insurance claim, please also notify the Head Coach and a member of the committee.

Do not admit liability, do not make an offer or promise to pay. 

Date of the incident: *
Date of the incident:
Time of the incident: *
Time of the incident:
Injured Person's Name *
Injured Person's Name
Injured Person's Address *
Injured Person's Address
Reporting Person's Name *
Reporting Person's Name
I agree that the information I have submitted on this form is true to the extent of my knowledge *