Please provide the following information regarding your injured child:

Please provide the following information as it applies to you:

Did the police respond to your child's accident? Yes No
If so, do you have a police report? Yes No
Was your child examined or treated at a hospital emergency room? Yes No
Was your child hospitalized? Yes No
Did your child see a doctor as a result of his or her injuries? Yes No
Is your child currently under a doctor's care for injuries sustained in this accident?  Yes No
How much time, if any, did your child lose from school? 

Description of Accident:
(Please include a description of what caused your child's accident, and who was at fault.)

Describe Your Child's Injuries:

For motor vehicle accidents, describe the damage to the vehicles: