Plymouth Alliance Church Incident Report

Contact Parents/Guardian Immediately if emergency!

Please record all information completely and accurately.

Name of Individual

Date of Incident

Time of Incident

Please write your detailed description of the incident: (What, Where, How, Outcome - include minor injuries) [ie. The child ran into a table cutting their head; blood was everywhere, we applied ice and pressure. There was a lot of blood on the carpet.]

Were Paramedics/Doctors Called?

Who Treated the Injured Party?

Was there Property Damage? What?

Witnesses Name & Addresses

Number of Students in Class

Number of Teacher/Helpers present

Preparer's Signature & Date

Parent/Guardian Signature & Date

Child's Information (Name, Address, Phone)

Description

This form must be completed accurately within three hours of the incident. Please fill out this form and click submit.

Plymouth Alliance Church Incident Report

Description

Please Fix the Following