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Kids City / Drive Incident Report
Staff Request
Kids City/Students Incident Report
Childs/Students Name Involved
*
Date
*
MM slash DD slash YYYY
Time
*
:
Hours
Minutes
AM
PM
AM/PM
Incident Description
*
Action Taken
*
Volunteer/Staff Member
*
Witness
I am aware of the incident which occurred on the stated date and time and agree with the action taken by Mile City Church.
Electronic Signature of Adult or Parent/Legal Guardian
*
Date
*
MM slash DD slash YYYY
Electronic Signature Director
*
Date
*
MM slash DD slash YYYY
*A Director must sign all incident reports. If the Director is away from the building, please contact safety to locate another Mile City Church Director/Staff member to sign.
