CARROLL COUNTY DEPARTMENT OF RECREATION AND PARKS Participant Accident

CARROLL COUNTY DEPARTMENT OF RECREATION AND PARKS

Participant Accident - Injury Form
Reported By:*
Date Occurred:*
Date Reported:*
Site/Location:*
Address of Site/Location:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Time Occurred:*
Time Reported:*
Program Name/Recreation Council/Organization:*
Name of Person Injured:*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Date of Birth:*
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
in personby phoneemail
HeadBackChest/RibsFaceEyeEarNoseMouthTeethNeck/ThroatShoulder/Collar BoneAbdomenBackArmElbowWristHandFinger/ThumbLegKneeAnkleFootToesOther
Name of Staff/Volunteer Providing Care:*
Contact info of Staff/Volunteer Providing Care:*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Ambulance Called
Hospital/Medical Contact:*
Care Given:*
Witness 1:

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Witness 2:

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Description of Accident/Injury (in detail, facts only): Use back or attach additional sheets if necessary.*
Parent/Guardian Signature (if available)*

Clear
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Staff/Volunteer Completing form:

First NameLast Name
Staff/Volunteer Signature:

Clear
Reports are due within 24 hours. Serious Accidents: email report immediately to Lisa Carroll at lcarroll@carrollcountymd.gov or designated supervisor OR Fax to CCRP at 410-876-8284
Should be Empty: