Student Incident Report | Fishers of Men Bible & Music Centers

An incident concerning your child occurred at the center.

Date / Time of the Incident *

Date

Time

Student Name *

First

Last

Location of the Incident

Description of the Incident *

Names of People Involved in the Incident

Specific names of other students involved will not be disclosed on the incident report to prevent retaliation

Was anyone injured during the incident?

Description of Injuries

Was any property damaged during the incident?

Description of Property Damage

Were any actions taken during the incident?

First aid given at the facility: *

Description of Action Taken

Names of Witnesses to the Incident

Name of Staff Person Reporting the Incident *

First

Last

Name of Parent/ Guardian that was informed *

First

Last

Parent / Guardian Signature *

Clear Signature