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:_____________________________