University City United Methodist Church

University City United Methodist Church Accident, Incident, & or Property Damage Report

Description of Incident :

Choose all applicable descriptions :

Accident (Injury Involved)

Incident (No Injury Involved)

Property Damage

Name & Address of Reserving Individual / Organization's Designated on-site Representative :

First Name

Last Name

Address

Apartment, suite, etc.

City

State

Zip/Postal Code

Phone Number

Details of Accident/Incident/Property Damage

Date Accident/Incident/Property Damage Occured :

Time Accident/Incident/Property Damage Occured :

Location Accident/Incident/Property Damage occured on UCUMC Property :

Room Number (if applicable) :

Details of Accident/Incident/Property Damage :

Actions Taken after Accident/Incident/Property Damage :

Information of Person Injured

First Name

Last Name

Address

Apartment, suite, etc.

City

State

Zip/Postal Code

Phone Number

Reason Person Injured was on UCUMC Premises :

Details of the Injury sustained :

Is the person injured a minor (under the age of 18)?

Does the Person Injured have Personal Medical Insurance?

Was the Person Injured taken to a Hospital or Doctor?

What Adult was responsible for the supervision of the Minor at the time of the Injury

First Name

Last Name

Address

Apartment, suite, etc.

City

State

Zip/Postal Code

Phone Number

Email

Parent/Guardian Information of Minor Person Injured

First Name

Last Name

Address

Apartment, suite, etc.

City

State

Zip/Postal Code

Phone Number

Email

Personal Medical Insurance Information

Personal Medical Insurance Company :

Personal Medical Insurance Company Phone Number :

Name of Person who carries the personal medical insurance policy :

Hospital/Doctor's Office Information

Name of Hospital/Doctor's Office

Address

Apartment, suite, etc.

City

State

Zip/Postal Code

Phone Number

How was the Person Injured Transported?

Witness 1 Information

First Name

Last Name

Address

Apartment, suite, etc.

City

State

Zip/Postal Code

Email

Phone Number

Signature

Witness 2 Information

First Name

Last Name

Address

Apartment, suite, etc.

City

State

Zip/Postal Code

Email

Phone Number

Signature

I agree that all information has been reported accurately according to my knowledge

Signature