Accident/Incident Report

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 NameLast Name
Date of Birth*

MonthDayYear
Troop or Community/Area Name or Number*
To look up your community/area name or number, see our Community/Area Roster.
Girl Scout/Volunteer Address*

Street Address

Street Address Line 2

CityState / 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 NameLast Name
Parent/Guardian/Emergency Contact Address (if different from above)

Street Address

Street Address Line 2

CityState / 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*

MonthDayYear
Date Event Ended*

MonthDayYear
Date of Accident/Incident*

MonthDayYear
Time of Accident/Incident*

Hour Minutes

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

CityState / 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/GuardiansDoctor/Hospital/ClinicCouncilOthers
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 NameLast Name
Your Email*
example@example.com
Date of Signature

MonthDayYear
Should be Empty:

Accident/Incident Report

Girl Scout/Volunteer Information

Accident/Incident Information

Signature