Penn St.-Worthington-Scranton
2035810-50927000PSUAC ATHLETIC INJURY REPORTName of injured participant:Current Address:Parent’s Name:Parent’s AddressCampus Where Enrolled:Semester Standing:Age:Sport:Place of AccidentDate and Time of Accident:Nature of Injury342905206900Type of Medical Treatment Obtained:3429011747400Family or Personal Medical Insurance Available? YesNoIf Yes, Please Identify the Insurance Company:I certify that the above information is correct:Signature of Participant:Signature of Activity Supervisor: Witness to Accident: (Name and Address) ................
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