Margaret River Holiday 13 – 17 Feb

Margaret River Swim Holiday
Fill out the details to book your trip
Terms and Conditions
Make sure you read and understand the terms and conditions
Price $AUD
Prices vary between twin share and single room
$500 deposit to secure booking

Name of Person completing report(Required)
First Last
Date of incident(Required)
DD slash MM slash YYYY
Time of incident(Required)

: Hours

Minutes

AM/PM
Location of incident(Required)

Provide details on weather, physical environment, and surroundings
Name of Person report pertains to(Required)
First Last
Phone (if known)
Email (if known)
Type of Incident(Required)
- major First Aid
- Minor First Aid
- Major Rescue
- Drowning
- Jellyfish Sting
- Bike Injury
- Interaction with wild animal
- Employee Injury
- Complaint
- Other - provide details below
Nature of injury
- Marine Sting
- Abrasion / graze
- Blisters
- Open wound /laceration / cut
- Bruise / contusion
- Inflammation / swelling
- Fracture (including suspected)
- Dislocation/subluxation
- Sprain / Strain
- Overuse injury
- Concussion
- Cardiac problem
- Respiratory problem / Asthma
- Loss of consciousness
- Heat stroke / Heat exhaustion
- Hypothermia
- Sunburn
- Suspected spinal
- Other (provide details below)
Body parts affected(Required)
Type of activity at time of incident(Required)
Administered treatment(Required)
What did you do?
What did anyone else do, who were they?
Did you perform first aid?
What medications were given if any
Witnesses to incident
Name Phone Email
After Care Referral
- No referral
- Ambulance transport
- Dr
- Peer Counselling

Name	Phone	Email