Member Accident Report
General Instructions:
This form must be completed by the adult in charge for all accidents resulting in injury.
Submit all information within 48 hours of the accident.
If the accident resulted in police involvement, please upload a copy of the police report.
If the media was contacted or present as a result of the accident, please refrain from making comments on behalf of Girl Scouts of Southeast Florida and contact Director of Marketing and Communications, Melinda Glasco, at (772) 631-6893, for official council response and information.
Please direct any questions regarding completion of this form to Heather Hileman, Senior VP of Mission Delivery, at hhileman@gssef.org.
Who is this report for?
*
A girl member
An adult member
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Girl Accident Report
Girl's Name
*
First Name
Last Name
Parent's Name
*
First Name
Last Name
Parent's Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Parent's Email
*
example@example.com
Troop Number
*
Service Unit
*
Please Select
712 Everglades
716 Jupiter
729 Sandy Beaches
742 Royal Palm
743 Phoenix
745 Sea Star
746 Indian Treasure
748 Sunchariot
749 Blazing Star
750 Orange Blossom
753 Luna
754 Kowechobe
755 Magnolia
756 Atikah
757 Wildflower
758 Hibiscus
759 Gemini
760 Aquarius
761 Sunflower
I don't know
Activity Leader/Advisor Name
*
First Name
Last Name
Leader/Advisor Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Leader/Advisor Email
*
example@example.com
Accident Information
Date of Accident
*
-
Month
-
Day
Year
Date
Time of Accident
*
Hour Minutes
AM
PM
AM/PM Option
Location of Accident
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Nature of Accident
*
Were the parents notified?
*
Yes
No
Was the Media present?
*
Yes
No
Witnesses
Number of witnesses
*
Please Select
No witnesses
1
2
3
Witness #1 Name
*
First Name
Last Name
Witness #1 Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Witness #1 Email
*
example@example.com
Witness #2 Name
*
First Name
Last Name
Witness #2 Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Witness #2 Email
*
example@example.com
Witness #3 Name
*
First Name
Last Name
Witness #3 Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Witness #3 Email
*
example@example.com
Treatment
Treatment or Immediate Action Taken
*
Physician's Name (if applicable)
First Name
Last Name
Hospital's Name (if applicable)
First Aider Name (who responded/provided assistance)
*
First Name
Last Name
First Aider's Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
First Aider's Email
example@example.com
First Aider's Certification Expiration Date (First Aid)
-
Month
-
Day
Year
Date
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Adult Accident Report
Registered Member/Volunteer’s Name (injured adult):
*
First Name
Last Name
Member’s Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Troop Number
*
Service Unit
*
Please Select
712 Everglades
716 Jupiter
729 Sandy Beaches
742 Royal Palm
743 Phoenix
745 Sea Star
746 Indian Treasure
748 Sunchariot
749 Blazing Star
750 Orange Blossom
753 Luna
754 Kowechobe
755 Magnolia
756 Atikah
757 Wildflower
758 Hibiscus
759 Gemini
760 Aquarius
761 Sunflower
I don't know
Activity Leader/Advisor Name
*
First Name
Last Name
Leader/Advisor Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Leader/Advisor Email
*
example@example.com
Accident Information
Date of Accident
*
-
Month
-
Day
Year
Date
Time of Accident
*
Hour Minutes
AM
PM
AM/PM Option
Location of Accident
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Nature of Accident
*
Was the Media present?
*
Yes
No
Witnesses
Number of witnesses
*
Please Select
No witnesses
1
2
3
Witness #1 Name
*
First Name
Last Name
Witness #1 Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Witness #1 Email
*
example@example.com
Witness #2 Name
*
First Name
Last Name
Witness #2 Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Witness #2 Email
*
example@example.com
Witness #3 Name
*
First Name
Last Name
Witness #3 Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Witness #3 Email
*
example@example.com
Treatment
Treatment or Immediate Action Taken
*
Physician's Name (if applicable)
First Name
Last Name
Hospital's Name (if applicable)
First Aider Name (who responded/provided assistance)
*
First Name
Last Name
First Aider's Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
First Aider's Email
example@example.com
First Aider's Certification Expiration Date (First Aid)
-
Month
-
Day
Year
Date
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Documentation
Upload Supporting Documents
Browse Files
Drag and drop files here
Choose a file
You can upload supporting documents such as a Police report, witness statement, photo, etc. - If the police were involved, a Police report must be uploaded.
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Name of person filing this report:
*
First Name
Last Name
Email of person filing this report:
*
example@example.com
Today's date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: