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Accident/Incident Report
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Date & Time of Incident
*
Date & Time of Incident
Date & Time of Incident
Incident Location
*
Description of Incident
*
Please describe the incident in detail here.
INVOLVED PARTY
Name
Age
Phone Number
Parent/Guardian Name (if under 18)
Parent/Guardian Phone Number
Address
Neighborhood
-- Select One --
Meadow View
Mountain View
The Arbors
The Grange
The Groves
The Knolls
The Oaks
The Orchard
The Timbers
The Village
The Vineyards
The Willows
Please check one
*
Victim
Witness
Offender
Victim of:
Theft
Vandalism
Items stolen or damaged
Was an injury sustained?
*
-- Select One --
Yes
No
If yes, describe the injury.
Did staff provide care?
-- Select One --
Yes
No
If yes, please describe care provided.
INVOLVED PARTY (additional)
Name
First and Last
Age
Phone Number
Parent/Guardian Name (if under 18)
Parent/Guardian Phone # (If under 18)
Address
Neighborhood
-- Select One --
Meadow View
Mountain View
The Arbors
The Grange
The Groves
The Knolls
The Oaks
The Orchard
The Timbers
The Village
The Vineyards
The Willows
Please check one
Victim
Witness
Offender
Victim of:
Theft
Vandalism
Items stolen or damaged
Was injury sustained?
-- Select One --
Yes
No
If yes, describe the injury.
Did staff provide care?
-- Select One --
Yes
No
If yes, please describe care given.
Were emergency services called?
*
Yes
No
If yes, which services were called?
Police
Fire Department
Ambulance
Police or Emergency Officials Name
First and Last
Report # (if applicable)
If yes, who called for services?
Signature
*
By checking the "I agree" box below, you agree and acknowledge that 1) your statement is true to the best of your knowledge, 2) by signing you authorize Power Ranch Community Association and its affiliates to file and report all information provided as necessary by law.
I agree.
Electronic Signature
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