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/incident. Girl Scouts River Valleys will reach out to you within 5 business days and provide assistance as appropriate. Use the form below or print and mail the paper version.Girl/Volunteer InformationIn this section, please provide the contact information for the girl or volunteer who was injured or acquired an illness. Name of Girl/Volunteer* First Last Date of Birth* Month Day Year Troop Number or Service Unit Name or Number* To look up your service unit name or number, see our service unit directory.Girl/Volunteer Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Home Phone Number*Work Phone NumberPrimary Insurance Carrier* Policy Number* Parent/Guardian/Emergency Contact NameIf different from above. First Last Parent/Guardian/Emergency Contact AddressIf different from above. Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Are you a staff member? Yes, I am Girl Scouts River Valleys Staff. Accident/Incident InformationIn this section, please provide information about the accident or incident. Event Name* Session Number Date Event Began* Month Day Year Date Event Ended* Month Day Year Date of Accident* Month Day Year Time of Accident* Place Where Accident Occured*i.e., troop house, kitchen, program center, camp fire, etc. Accident/Incident Description*Describe the accident/incident giving as much information as possible.Injury/Illness Description*Describe the injury/illness giving as much information as possible.Treatment Description*Describe the treatment given and by whom. Name of Physician/Hospital/Clinic* Physician/Hospital/Clinic Phone Number*Physician/Hospital/Clinic Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code WitnessesList any witness names and phone numbers. Use the symbol to add additional witnesses.NamePhone Number Who was notified?Check all those who were notified of the incident/accident. Parents/Guardians Doctor/Hospital/Clinic Council Others Council Notified*You checked "Council," please describe who, at River Valleys, was notified of the incident/accident. Others Notified*You checked "Others," please describe who was notified of the incident/accident. SignatureBy adding your name, you are confirming that all the above information is accurate.Your Name* First Last Your Email*
