CC Incident/Injury Report

Your name *

Email address *

Incident/Injury Information

Name of Injured Person *

Age *

Ambulance called *

Location of incident/injury *

Time of incident/injury *

Witness Name (if applicable)

Incident Description: *

Medical Attention Provided *

Pictures of Incident

Please provide any pictures documenting the incident if applicable

No files currently selected

Add up to 5 files. Maximum file size 10 MB.

Electronic Signature of Ministry Director Notified *

The Ministry Director overseeing the event, over the person who was injured. (ie. child injured, would be the Kids Ministry Director, etc)

Phone Number of Parent/Guardian *

Parent/Guardian Electronic Signature *

I, agree and understand that by signing the Electronic Signature Acknowledgment and Consent Form, that all electronic signatures are the legal equivalent of my manual/handwritten signature and I consent to be legally bound to this agreement.

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