*1.Site Director(Required.)

Blackburn, JaredCamp All-AmericanCason, SkyGable, JonGraham, BunnyHeard, JenniferHilburn, AmyTokos, ThomasWhisenant, JonWolfe, Sarah ElizabethOther (please specify)

*2.Person Filling out this form(Required.)

*3.Group(Required.)

*4.Facilitator(s)/Counselor(s) Involved(Required.)

*5.Element/Activity(Required.)

6.Participant Type (if applicable)

ChildTeenagerAdultFacilitatorN/A

*7.Type of Incident(Required.)

Unauthorized Access to CourseUnclipped at HeightRescue from HeightFall from HeightRope BurnScrape, Cut,  or AbrasionBump, Bruise, Strain, SprainHead, Neck, or Back PainBloody NoseOther (please specify)

*8.Description of Incident(Required.)

*9.Policy/Procedure(s) Violated to cause incident:(Required.)