Please complete the form with as much detail as possible. Clicking the submit button will send a copy of the form to the Chairman of Southeast London U3A.

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Name of injured party or property owner. *

First

Last

Address of injured person or property owner and telephone number.

Date and time of incident.

Location of incident

Group witnesses. and

Circumstances of accident / incedent.

Injury / property damage details.

Name, Address and Telephone number of other people involved in the accident or incident.

Names and addresses of any witnesses.

Immediate action taken.

Details of any specialised assistance required at the scene.

Was medical advice sought afterwards? If so give details.

Name of Group Leader/Convenor. *

First

Last

Group leaders Phone number and email address. *

Date of Submisson of this form.

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