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SFGH Incident Report

 

This form is required for every incident or accident, with or without injury.   When an incident occurs, this form must be completed and Owner or Instructor must be notified immediately.    

 

 

 

 

 

 

 

 

 

 


 

 

 

Please select who will be participating...
AdultMinor
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First Participant's Name

First Name*

Middle Name

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Signature*
Parent or Guardian's Email Address

Email
Check to receive information, news, and discounts by e-mail.
Your signed waiver will be sent to the email address provided here and is available for download for three days via URL attachment.
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*
Incident

Date of Incident *

Time of Incident *
Was there an injury?*
No
Yes

Please describe Incident in Full detail-Paint the picture Of the events, explain activity leading up to incident and what incident occurred. *
Who was injured:*
What was going on when the incident took place?*
Was Medical Attention Required?*
No
Yes

Type of Medical Attention needed such as Ambulance called, Doctor Visit, None Needed ETC *

Describe Injuries *
Barn Owner or Instructor Notified at the Time of the incident ?*
No
Yes

Witnesses to Incident. List full names *

Follow up on incident & ways incident could of been prevented *
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Relationship*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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