Dynamyx Injury and Accident Report Form

Please complete this form in full (one per incident) and submit to Dynamyx within 48 hours of the incident. *If a concussion is suspected, please completed the Dynamyx Concussion Incident Report. Only currently registered Alberta Gymnastics members are covered by the Sport Accident Insurance Policy (birthday party and other one-time participants are NOT covered).

Individual Experiencing Injury 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 phone number *

Gender

Date of birth *

Address

City

State/Province

Zip/Postal code

Other phone (home or work)

Please Select Their GymBC Club: *

What Is Their Role? *

Gymnast Level *

Years of Experience *

Supervising Coach *

Please include the first and last name of the person instructing the participant's class/program

Injury Details

Injured Body Part *

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

Side *

Right Left Both NA

Date of Injury/Accident

Time of injury *

How many minutes into training did the injury occur? *

Occasion: *

How did the incident occur? *

Apparatus/Area - Select all that apply *

Situation *

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 happened (include any special or unusual circumstances related to the incident): *

Action Taken

What action did you take? *

By whom (First and Last Name) *

Phone *

Describe:

Name of hospital / clinic (if applicable)

Transported by:

When was the parent informed?

Informed by:

Coach Staff Other

First and Last Name

Witnesses

Witness #1

First name

Last name

Mobile phone number

What is their role?

Witness #2

First name

Last name

Mobile phone number

What is their role?

If it is likely that the injured party will make an insurance claim, please ensure that they receive a copy of the GameDay Sport Accident Claim Form and instructions on making claims. These are available on the GBC website. The claim form must be submitted to Gymnastics BC within 30 days of the incident. Gymnastics BC will forward the form to GameDay Insurance. Please keep all documentation and receipts related to medical care from the incident to facilitate the claims process.

Upload an image

Submitted by:

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

First name *

Last name *

Email *

Mobile phone number

Other phone

Role

Electronic signature *

Please sign your name inside the box

×

Who will be participating?

Adult Adult and Children Children

Signee Information

First Name *

Last Name *

Your Date of Birth *

Phone *

Email Address *

Address *

Address Line 2

City *

Province *

Postal Code *

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By clicking 'I Agree' below, you agree that you have read and agree with the terms of the waiver and that the information you provided is accurate. You furthermore agree that your submission of this form, via the 'I Agree' button, shall constitute the execution of this document in exactly the same manner as if you had signed, by hand, a paper version of this agreement.

Dynamyx Injury and Accident Report Form

Individual Experiencing Injury Information:

Please Select Their GymBC Club: *

What Is Their Role? *

Gymnast Level *

Years of Experience *

Supervising Coach *

Injured Body Part *

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

Side *

Date of Injury/Accident

Time of injury *

How many minutes into training did the injury occur? *

Occasion: *

How did the incident occur? *

Apparatus/Area - Select all that apply *

Situation *

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 happened (include any special or unusual circumstances related to the incident): *

Action Taken

What action did you take? *

By whom (First and Last Name) *

Phone *

Describe:

Name of hospital / clinic (if applicable)

Transported by:

When was the parent informed?

Informed by:

Witness #1

What is their role?

Witness #2

What is their role?

Upload an image

Submitted by:

Role

Electronic signature *

Who will be participating?

Signee Information

Please enter participants' full names:

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