List what statements were made to whom and by whom (Attach additional pages if needed):
List all witnesses:
Name
Phone
Age
Address
Street
City
State
Name
Address
Zip
Phone
Street
City
Age
State
Zip
List other involved (i.e., police, fire department, etc):
For those incidents involving medical treatment::
Was the victim transported to the hospital?
Yes No
By Whom?
Name of hospital
What was the diagnosis?
If an ambulance/rescue service was called:
Name of ambulance/rescue service
Address
Name/position of staff member who made a follow-up phone call to the parent/guardian?:
Name of staff member
Position
What were to results of the follow-up phone call?
List any corrective action steps that were taken to prevent the accident/incident from occurring in the
future:
Signature of leader or event director
Date
EMERGENCY INFORMATION
Call for emergency help
Alert GSWPA Corporate office: 1-800-248-3355 (M-Th 8:30 a.m.-5 p.m., Fri 9 a.m.-noon) or 1-877-3597878 (after business hours). Refer all inquires and media requests for information: GSWPA Corporate office: 1-800-248-3355.
Speak only to the police and proper authorities. Do not sign any statements or reports, except for police.
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