Accident Report

Child’s Name: _______________________________________

Date of accident: _____________________________________

Approximate Time of accident: __________________________

Accident:
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What First Aid was given by Provider?

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Where parents call or told at pick up: __________________________________

Was an ambulance called: _________________

Did the child need to go to the hospital: __________________________

Will the parents be taking the child to be seen by a doctor: _____________________________________

Parents Signature: _______________________________________, Date: _________________________

Providers Signature: ______________________________________, Date: ________________________