ࡱ> TVS'` #bjbjLULU 46.?.?hhhhhhhd8lR %zvvvvvFdMOOO'vL!L%$&h)f2%9h[vv[[2%hhvvk%uuu[(hvhvMu[Muuhhuvn g_u9%0%uu)u)uu)huZ>@u~42%2%e%[[[[       |hhhhhh CLUB ACCIDENT REPORT (PLEASE PRINT) CALIFORNIA SQUARE DANCE COUNCIL INSURANCE PROGRAM ASSOCIATION / FEDERATION: Northern California Square Dancers Association CLUB:  FORMTEXT       DATE OF ACCIDENT:  FORMTEXT       CLUB OFFICER:  FORMTEXT       TELEPHONE: ( FORMTEXT    )  FORMTEXT    - FORMTEXT      LOCATION OF ACCIDENT:  FORMTEXT       NAME OF PERSON INJURED:  FORMTEXT       ADDRESS:  FORMTEXT       TELEPHONE: ( FORMTEXT    )  FORMTEXT    - FORMTEXT      CLUB:  FORMTEXT       ASSOCIATION:  FORMTEXT       NATURE OF INJURY:  FORM(*,DLH R T V X l n p z | ( N P d ѴnW-jhX?H5OJQJU^JaJmHnHu.jhX?HhpT5OJQJU^JaJ"jhX?H5OJQJU^JaJhX?H5OJQJ^JaJh|0h{nCJOJQJ^Jh|0hdOJQJ^Jh|0hd6CJOJQJ^Jh|0hdCJOJQJ^Jh|0hdCJOJQJ^Jh|0hd5CJOJQJ^J*HJLJ 4 T   dhgd\2x  C dhgd\2x C 2$ $d %d &d 'd N O P Q ^`a$$ C a$##d f h r t T f h l n p ֳֈpY֤J8"jhv5OJQJU^JaJh|0h{nOJQJ^JaJ-jhX?H5OJQJU^JaJmHnHu.j hX?HhpT5OJQJU^JaJhX?H5OJQJ^JaJh|0h{nCJOJQJ^Jh|0hdCJOJQJ^J h|0hd0JCJOJQJ^J"jhQ5OJQJU^JaJ"jhX?H5OJQJU^JaJ.jhX?HhpT5OJQJU^JaJp ȱȢkT*CJOJQJ^J   " $ * , . 0 D F H P R T \ ëД|ДlTДDh|0hd5OJQJ^JaJ.jb hX?HhpT5OJQJU^JaJh|0h\2x5OJQJ^JaJ.j` hX?HhpT5OJQJU^JaJ-jhX?H5OJQJU^JaJmHnHu.j^ hX?HhpT5OJQJU^JaJhX?H5OJQJ^JaJ"jhX?H5OJQJU^JaJh|0h\2xOJQJ^JaJh|0hdCJOJQJ^J\ b d x z |   Һߣߓlߣ߄jRߣ.jhX?HhpT5OJQJU^JaJU.j"hX?HhpT5OJQJU^JaJh|0hdCJOJQJ^Jh|0h\2x5OJQJ^JaJ-jhX?H5OJQJU^JaJmHnHu.jd hX?HhpT5OJQJU^JaJhX?H5OJQJ^JaJ"jhX?H5OJQJU^JaJh|0h\2xCJOJQJ^JTEXT       DESCRIPTION OF ACCIDENT:  FORMTEXT       WHEN & WHERE WAS TREATMENT GIVEN:  FORMTEXT       NAME & ADDRESS OF WITNESS: 1.  FORMTEXT       2.  FORMTEXT       3.  FORMTEXT       SIGNED: TELEPHONE: ( FORMTEXT    )  FORMTEXT    - FORMTEXT      FAX: ( FORMTEXT    )  FORMTEXT    - FORMTEXT      E-MAIL:  FORMTEXT       PLEASE COMPLETE FORM WITHIN 72 HOURS OF AN ACCIDENT AND SEND TO: NCSDA Membership Chairman Peggy Rose & Ethlyn  Babe Sandau PO Box 1117 Brentwood, CA 94513 (925) 240-1117  HYPERLINK "mailto:ncsdainsurance@sbcglobal.net" membership@ncsda.com     August 2011 JLPRfhjtvx$࿲s࿲[Lh|0h'OJQJ^JaJ.jh>hpT5OJQJU^JaJh|0hd5OJQJ^JaJ-jh>5OJQJU^JaJmHnHu.jh>hpT5OJQJU^JaJh>5OJQJ^JaJ"jh>5OJQJU^JaJh|0h'CJOJQJ^Jh|0hdCJOJQJ^Jh|0hd>*CJOJQJ^JxL|N X!!!"H"""""#### gdv mdh^gd\2x dh^gd\2x  dhgd\2x  dhgd\2x$&:<>HJLTVjlnxz|N ` b f {cTTh|0h'CJOJQJ^J.jphQhpT5OJQJU^JaJ.jJhQhpT5OJQJU^JaJh|0hdCJOJQJ^Jh|0hd>*CJOJQJ^J-jhQ5OJQJU^JaJmHnHu.j$hQhpT5OJQJU^JaJhQ5OJQJ^JaJ"jhQ5OJQJU^JaJf h j ~ Һߣҋߣ|j]Ej.j*hvh|b5CJOJQJU^Jhv5CJOJQJ^J"jhv5CJOJQJU^Jh|0h'CJOJQJ^J.jhvh|b5OJQJU^JaJ-jhv5OJQJU^JaJmHnHu.jhvh|b5OJQJU^JaJhv5OJQJ^JaJ"jhv5OJQJU^JaJh|0h'OJQJ^JaJ !!! !!!$!&!(!.!ƷzbKz3K.jhvh|b5OJQJU^JaJ-jhv5OJQJU^JaJmHnHu.jxhvh|b5OJQJU^JaJhv5OJQJ^JaJ"jhv5OJQJU^JaJh|0h'OJQJ^JaJh|0h'CJOJQJ^Jh|0hdCJOJQJ^Jh|0hd>*CJOJQJ^J"jhv5CJOJQJU^J-jhv5CJOJQJU^JmHnHu.!0!2!4!H!J!L!T!V!X!d!f!h!j!~!!!!!͑́rreM6-jhv5OJQJU^JaJmHnHu.j hvh|b5OJQJU^JaJhv5OJQJ^JaJh|0hdCJOJQJ^Jh|0hd>*CJOJQJ^J-jhv5CJOJQJU^JmHnHu.jhvh|b5CJOJQJU^Jhv5CJOJQJ^J"jhv5CJOJQJU^Jh|0h'CJOJQJ^J"jhv5OJQJU^JaJ!!!"4"F"H"b""""""""T#V#X#####²rYrHr9hQhQOJQJ^JaJ hL0JOJQJ\]^JaJ1j!hhQOJQJU\]^JaJ%jhQOJQJU\]^JaJhLOJQJ\]^JaJhOJQJ\]^JaJhQOJQJ\]^JaJhd5OJQJ\]^JaJhQ5OJQJ\]^JaJh,(i5OJQJ\]^JaJhv5CJOJQJ^Jh|0hd5CJOJQJ^J####################hQhQOJQJ^JaJhjUhCJaJhLCJaJhPhjUCJaJhh jh U##########  dhgd\2xgdP 2&P:pv/ =!"#$%& DText2Enter your Club name.Enter your Club name.DDText3MM/dd/yy0Enter date of accident. Format as "mm/dd/yy".0Enter date of accident. Format as "mm/dd/yy".DText4*Name of Club Officer filling-out the form.*Name of Club Officer filling-out the form.LD Text56Telephone number of Club Officer filling-out the form.6Telephone number of Club Officer filling-out the form.LD Text66Telephone number of Club Officer filling-out the form.6Telephone number of Club Officer filling-out the form.LD Text76Telephone number of Club Officer filling-out the form.6Telephone number of Club Officer filling-out the form.DText8%Facility name, room, city, and state.%Facility name, room, city, and state.XDText99Full name of the injured person. DO NOT USE NICKNAMES.9Full name of the injured person. DO NOT USE NICKNAMES.DText10Full address of injured person.Full address of injured person.DText11#Telephone number of person injured.#Telephone number of person injured.D Text12#Telephone number of person injured.#Telephone number of person injured.D Text13#Telephone number of person injured.#Telephone number of person injured.DText14RThe full Club name the injured person is a member of. DO NOT USE ABBREVIATIONS!RThe full Club name the injured person is a member of. DO NOT USE ABBREVIATIONS!DText15KThe full Association name the Club belongs to. DO NOT USE ABBREVIATIONS.OThe full Association name the Club belongs to. DO NOT USE ABBREVIATIONS.6DText160A description of what was injured on the person.0A description of what was injured on the person.~DText17BEnter a description of the accident in as much detail as possible.BEnter a description of the accident in as much detail as possible.DText18When and where treatment was given, starting with that given at location of accident. If injured person did not want treatment, indicate this as well.~When and where treatment was given, starting with that given at location of accident. For more information, use the F1 key.&DText19,List full name and address of any witnesses.,List full name and address of any witnesses.&DText20,List full name and address of any witnesses.,List full name and address of any witnesses.&DText21,List full name and address of any witnesses.,List full name and address of any witnesses.FDText222Telephone number of Club Officer signing the form.6Telephone number of Club Officer filling-out the form.NDText236Telephone number of Club Officer filling-out the form.6Telephone number of Club Officer filling-out the form.NDText246Telephone number of Club Officer filling-out the form.6Telephone number of Club Officer filling-out the form.D,Fax number of Club Officer signing the form.,Fax number of Club Officer signing the form.D,Fax number of Club Officer signing the form.,Fax number of Club Officer signing the form.D,Fax number of Club Officer signing the form.,Fax number of Club Officer signing the form.2DText25/Email address of Club Officer signing the form./Email address of Club Officer signing the form.DyK ncsdainsurance@sbcglobal.netyK `mailto:ncsdainsurance@sbcglobal.netyX;H,]ą'cH@H Normal5$7$8$9DH$_HmH sH tH DA@D Default Paragraph FontViV  Table Normal :V 44 la (k(No List <O< p6 ^`CJ$O$ c5CJ$O$ p4CJ$O"$ c3CJ<O2< p2 @ @ ^@ `CJ<OB< p1 pp^p`CJ$OR$ p0CJ<Ob< p3 pp^p`CJ8Or8 Default TextCJHOH InitialStyle@B*CJOJQJkH4@4 rHeader  !4 @4 rFooter  !6U@6 Q Hyperlink >*B*ph6 z$%&FXYZ[CGe<s'l $GShx$5$X$d$d$TM$TM$d$d$d$$$$$$$$$$$$$LS$$$$LS$$$$w$w$$$$$$$L$%&FXYZ[CGe<s'l $GShx0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@000@0@000@000$@000$@000$@000$0@000$$%&FXYZ[CGe<s'l $GShx@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0 d p \ $f .!!## ### '39R^d3?EQ]cr~ (4:_kq4@DGSWYejtxFFFFFFFFFFFFFFFFFFFFFFFFFFFXText2Text3Text4Text5Text6Text7Text8Text9Text10Text11Text12Text13Text14Text15Text16Text17Text18Text19Text20Text21Text22Text23Text24Text25'R3Qr(_4GY :eFd ;rEXk d&  &  $'  d'  DF  F GGSS^bMR\`gg8*urn:schemas-microsoft-com:office:smarttagsCity>*urn:schemas-microsoft-com:office:smarttags PostalCode:*urn:schemas-microsoft-com:office:smarttagsStreet;*urn:schemas-microsoft-com:office:smarttagsaddress9*urn:schemas-microsoft-com:office:smarttagsState9*urn:schemas-microsoft-com:office:smarttagsplace DU 17?EW]:':Re3FQdr (;_r4EGXYkt1FG+*''d'(d*-e-|0)2H@CdCX?H/JjUf<^|be,(im{n\2x<Qrva^ M>S+5NpepTdFP?LT1d|T-E +B*@pdfFactoryFPP4:winspoolpdfFactory 4pdfFactory2pndXXLetterXFPWINWORD~XCourier New`K,pdfFactory2pndXXLetterXFPWINWORD~XCourier New`K,t,U 4PP P PUnknownG:Ax Times New Roman5Symbol3& :Cx Arial?5 :Cx Courier New"A  噃)$xx24d3QHX)?*CLUB ACCIDENT REPORTpeggypeggyOh+'0   @ L X dpxCLUB ACCIDENT REPORTpeggy2011 CLUB ACCIDENT REPORTpeggy1Microsoft Office Word@ @@&_@>_՜.+,D՜.+,@ hp|   ' CLUB ACCIDENT REPORT Title 8@ _PID_HLINKSA2Q$mailto:ncsdainsurance@sbcglobal.net  !"#$%&'()*+,-/0123456789:;<=>?@ABDEFGHIJLMNOPQRURoot Entry Fi_WData #1Table.u)WordDocument46SummaryInformation(CDocumentSummaryInformation8KCompObjq  FMicrosoft Office Word Document MSWordDocWord.Document.89q