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This incident report should be completed as soon as possible after the incident occurs and should include as detailed a description of the situation as possible. 

First Woker's Name
First Name*
Last Name*
First Woker's Age Acknowledgment*
First Woker's Date of Birth*
Date of Birth
I certify that I am 18 years of age or older
First Woker's Signature*
Second Woker's Name
First Name*
Last Name*
Woker's Date of Birth*
Date of Birth
Third Woker's Name
First Name*
Last Name*
Woker's Date of Birth*
Date of Birth
Fourth Woker's Name
First Name*
Last Name*
Woker's Date of Birth*
Date of Birth
Fifth Woker's Name
First Name*
Last Name*
Woker's Date of Birth*
Date of Birth
Sixth Woker's Name
First Name*
Last Name*
Woker's Date of Birth*
Date of Birth
Seventh Woker's Name
First Name*
Last Name*
Woker's Date of Birth*
Date of Birth
Eighth Woker's Name
First Name*
Last Name*
Woker's Date of Birth*
Date of Birth
Ninth Woker's Name
First Name*
Last Name*
Woker's Date of Birth*
Date of Birth
Tenth Woker's Name
First Name*
Last Name*
Woker's Date of Birth*
Date of Birth
Parent or Guardian's Email Address
Email
Incident Details
Student/s Full Name/s *

Nature of Injury/Incident *
Incident Date *
Incident Time *
Incident Location *
Names of all leaders present *

What happened? *

Why did it happen? *

What action was taken? *
Were parents/guardians contacted?*
Yes
No

Parents Response
Who can best verify the events you recorded? *
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*
Last Name*
Phone*
Parent or Guardian's Age Acknowledgment*
Parent or Guardian's Date of Birth*
Date of Birth
I certify that I am 18 years of age or older
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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