Incident Report

Rise Academy of Arts

275 SE PIONEER WAY

SUITE 100

OAK HARBOR, WA 98277

(360) 610-5450

Name of Athlete/Customer Injured / Caused Incident: *

First NameLast Name

Phone # of Athlete's Parent/Guardian or Customer Injured or Property Damaged:

Format: (000) 000-0000.

Email of Athlete's Parent/Guardian or Customer Injured or Property Damaged:

example@example.com

Name of Supervising Employee: *

First NameLast Name

Accident / InjuryProperty DamageBoth Injury and Damage to property

Approx. Time of Injury/Incident:*

:HourMinutesAM/PM Option

Date or Injury/Incident:*

Date

Name of Event/Class/Practice which injury or incident occurred*

Injured Body Part*

How did the Injury/incident occur, Please Describe in Detail: *

0/0

Witness(es) (If none, write "None") (Witness MUST be Older than 16): *

Phone Number of Witness:

Format: (000) 000-0000.

Athlete/Customer Injury / Incident