Girl Scout Council of the Mid-South

Accident/Incident Report
File this report within 24 hours of an accident/incident that occurs during a Girl Scout activity.
Fields marked with an asterisk * are required.

Person Involved/ Injured
First Name:*
Last Name:*
Home Phone:*
Work Phone: 
Cell Phone: 
Address:*
City:*
State:*
  Zip:*
  Troop #:*
Age Level:* D Br Jr Teen Girl Scout 11-17
 Classification:* Adult  / Girl
 Age / Sex:*   Male  / Female
Parent/Guardian (if minor), First Name:*
Parent/Guardian (if minor), Last Name:*
Parent/Guardian Home Phone:*
Parent/Guardian Work Phone: 
 Was Parent Notified:* Yes  / No
If so, by whom: 

Description of Accident/Incident
Date:* (mm/dd/yy)
Time:* (include am or pm)
Location:*
Type of Activity:*
Describe what happened and injury:*

Witnesses
First Name (Witness #1):
Last Name (Witness #1):
Phone:
Address:
City:
State:
  Zip:
First Name (Witness #2): 
Last Name (Witness #2): 
Phone: 
Address: 
City: 
State: 
Zip: 

Describe Care Given
Care given by whom, First name:*
Care given by whom, Last name:*
Describe Care Given:*

Medical Treatment
Physician's First name: 
Physician's Last name: 
Location: 
Hospital: 
Location: 
 Was person retained overnight in hospital?:  Yes  / No
If so, date released:  (mm/dd/yy)

Person Completing This Form
First Name:*
Last Name:*
Phone:*
Email: 
Address:*
City:*
State:*
  Zip:*
Girl Scout Position:*
Signature:*
(Typing your name here qualifies as a valid signature)
Date:* (mm/dd/yy)
   
   

                             
You may submit form electronically by clicking submit or print and deliver to the
Girl Scout Council of the Mid-South
Mail: PO Box 240246, Memphis, TN 38124-0246
Deliver: 2715 Kirby Parkway, Suite 1
Fax: (901) 797-2183