Accident/Incident Report
In the event of an accident/incident at a Girl Scout activity, this form should be submitted within 24 hours of the accident or incident. Girl Scouts River Valleys will reach out to you within 5 business days and provide appropriate assistance.
Use the form below or print and mail the
paper version
.
Girl Scout/Volunteer Information
In this section, please provide the contact information for the girl or volunteer who was injured or acquired an illness.
Name of Girl Scout/Volunteer
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date Picker Icon
Troop Number or Service Unit Name or Number
*
To look up your service unit name or number, see our service unit directory.
Girl Scout/Volunteer Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone Number
*
Please enter a valid phone number.
Work Phone Number (Optional)
Please enter a valid phone number.
Primary Insurance Carrier
*
Insurance Policy Number
*
Parent/Guardian/Emergency Contact Name (if different from above)
First Name
Last Name
Parent/Guardian/Emergency Contact Address (if different from above)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Are you a staff member?
Yes, I am a Girl Scouts River Valleys staff member.
Accident/Incident Information
In this section please provide information about the accident or incident.
Event Name
*
Session Number
Date Event Began
*
-
Month
-
Day
Year
Date Picker Icon
Date Event Ended
*
-
Month
-
Day
Year
Date Picker Icon
Date of Accident/Incident
*
-
Month
-
Day
Year
Date Picker Icon
Time of Accident/Incident
*
Hour Minutes
AM
PM
AM/PM Option
Place Where Accident/Incident Occurred
*
Examples: troop house, kitchen, program center, camp fire, etc.
Please provide a description of the accident/incident with as much information as possible.
*
Please provide a description of the injury/illness with as much information as possible.
*
Please provide a description of the treatment given and by whom.
*
Name of Physician/Hospital/Clinic
*
Physician/Hospital/Clinic Phone Number
*
Please enter a valid phone number.
Physician/Hospital/Clinic Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
List any witness names and phone numbers.
Who was notified? Check all those who were notified of the incident/accident.
Parents/Guardians
Doctor/Hospital/Clinic
Council
Others
Because you checked "Council," please describe who, at Girl Scouts River Valleys, was notified of the incident/accident.
*
Because you checked "Others," please describe who was notified of the incident/accident.
*
Signature
By adding your name, you are confirming that all the above information is accurate.
Your Name
*
First Name
Last Name
Your Email
*
example@example.com
Date of Signature
-
Month
-
Day
Year
Date Picker Icon
Submit
Should be Empty: