Athletic & Student Accident Notification of Injury Form
Tennessee Risk Management Trust
Part I: School Report
Date of Accident:_______________________ Time:_______________________
School System:_________________________________________________________
Name of School Child Attends:____________________________________
Phone Number:_______________________
First Name:_______________________________ Middle Initial:_________
Last Name:_______________________________
Social Security Number:_______________________ Birthdate:___________________
Grade:_______________ Gender:_______________
Part of Body Injured:________________________ Left or Right:__________________
Describe the injury and How Injury Occurred:____________________________________________________________________
____________________________________________________________________________
Name of Activity/Class:___________________________________________________
Person Completing Form:________________________________ Title:__________________________ Date Signed:______________________
Part II: Parent/Guardian Information
Name of Parent/Guardian:________________________________________________________
Address:_______________________________________________________________
City:_____________________ State:___________________ Zip:_______________
Daytime Telephone:_____________________________