Name of Person Involved *

First Name

Last Name

Date of Birth

MM

DD

YYYY

Gender *

Female

Male

Report Prepared by *

First Name

Last Name

Are you a Camp Eagle Staff Member *

No

Yes

Phone

(###)

###

####

Date of Report *

MM

DD

YYYY

Supervisor's Name *

First Name

Last Name

Date of Incident/Accident *

MM

DD

YYYY

Time of Incident/Accident *

Hour

Minute

Second

AM PM

Where did the incident/accident take place?

Camp Eagle Campus

Camp Eagle Lodging Areas or Buildings

Other Activity Not on Camp Property

Traveling to or from a Camp Excursion

Was there Supervision?

Yes

No

Is follow up needed? *

No

Yes