Alberta Gymnastics Federation - Alberta Gymnastics Injury and Incident Report Form

Injury and Incident Report Form

Please complete this form in full and submit to Alberta Gymnastics Federation within 48 hours of the incident. (one form per incident)

Only currently registered Alberta Gymnastics Federation members are covered by the Sports Accident Insurance policy (birthday party and other one-time participants are NOT covered).

Injured Individual Information

The injured athlete or their parent/guardian will receive a receipt of this information via email. Please use the athlete's home address instead of the club address, if possible.

First name *

Last name *

Email *

Mobile *

Gender

Date of birth *

Address

City

State/Province

Zip/Postal code

Other phone (home or work)

What Is Their Role? *

Please select their Alberta Gymnastics Federation Gym Club *

Discipline *

Acro Trampoline and Tumbling Men's Artistic Women's Artistic Gymnastics For All Parkour

Other:

Gymnast Level *

GFA - School Age GFA - Adult GFA - Active Start (Preschool Age) GFA - Active Start (Parent and Tot) Developmental - Gymnaestrada Developmental (Acro, F.A.S.T, WAG) Competitive (Acro, T&T, MAG, WAG)

Other

Years of Experience *

First time 0-1 2-3 4-9 10+ N/A

Supervising Coach *

Please include the First and Last name of the supervising coach.

Injury Details

Date & Time of injury *

Injury Classification *

1st time injury re-injury chronic

Type of Suspected Injury (Check all that may apply at the time of injury) This information may be updated following a formal medical diagnosis

Bone Bruise Bruise Concussion Dislocation Fracture Laceration Sprain

Other

Injured Body Part *

Side of body injury occurred *

Left Right Both N/A

Occasion that injury occured *

Birthday Party Camp Competition Course Drop-In Field Trip Lobby Training Training Camp

Other

How did the incident occur? *

Approach Mount Mid-routine Spotting Dismount/Landing/Takeoff Stretching/Conditioning/Warm-up

Other

Apparatus *

Situation *

Fall (Slip, trip, pushed, lost balance) Over-Rotated Under-Rotated Missed Collision with person Collision with object

Other

Accident Circumstances *

Gymnast Error Apparatus

Other

What skill was being attempted at the time of the incident? *

What progressions were taught before the gymnast attempted the skill? *

Was spotting (or other aids) used? *

What precautions were taken to prevent the incident? *

Please provide details on how the incident occurred (include any special or unusual circumstances related to the incident) *

Action Taken

What action was taken *

Who provided the care/action for the injured party? (First and last name) *

Phone *

Describe *

Name of hospital/clinic (if applicable)

Transported by:

When was the parent informed?

Informed by:

Coach Administrator/Staff Other

First and Last Name

Witness #1

First name *

Last name *

Email *

Mobile

What was their role?

Witness #2

First name *

Last name *

Email *

Mobile

What was their role?

If it is likely that the injured party will make an insurance claim, please direct them to the AGF Website to receive the application forms and process. Claim forms must be submitted to Alberta Gymnastics within 30 days of the incident, and ensure all documentation and receipts related to medical care from the incident are kept to facilitate the claims process.

Upload an image

Upload a video

Submitted by:

Please provide contact information for the individual who filled out this form.

First name *

Last name *

Email *

Mobile

Other phone

Role *

Electronic signature

Please sign your name inside the box

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Injury and Incident Report Form

Injured Individual Information

What Is Their Role? *

Please select their Alberta Gymnastics Federation Gym Club *

Discipline *

Gymnast Level *

Years of Experience *

Supervising Coach *

Date & Time of injury *

Injury Classification *

Type of Suspected Injury (Check all that may apply at the time of injury) *This information may be updated following a formal medical diagnosis *

Injured Body Part *

Side of body injury occurred *

Occasion that injury occured *

How did the incident occur? *

Apparatus *

Situation *

Accident Circumstances *

What skill was being attempted at the time of the incident? *

What progressions were taught before the gymnast attempted the skill? *

Was spotting (or other aids) used? *

What precautions were taken to prevent the incident? *

Please provide details on how the incident occurred (include any special or unusual circumstances related to the incident) *

What action was taken *

Who provided the care/action for the injured party? (First and last name) *

Phone *

Describe *

Name of hospital/clinic (if applicable)

Transported by:

When was the parent informed?

Informed by:

Witness #1

What was their role?

Witness #2

What was their role?

Upload an image

Upload a video

Submitted by:

Role *

Electronic signature

Type of Suspected Injury (Check all that may apply at the time of injury) This information may be updated following a formal medical diagnosis