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First name (Person of Incident)
Last name (Person of Incident)
Place of Incident
Other
Date and Time Accident/Incident Occurred
Place of Accident/Incident
Describe Accident/Incident
Describe Nature of Injury
Witness(es) to Accident/Injury
What action was Taken?
911 was called immediately
Medical evaluation, treatment and/or transport was refused AND I HAVE OBTAINED a copy of the EMS refusal form, AND the PERSON OF INCIDENT signed below.
Florida ELECTRONIC SIGNATURES (ss. 668.001-668.006)
By signing below, I acknowledge that I refuse evaluation, treatment and/or transport from EMS, against recommendations and I understand the potential harm it may cause. I release all EMS personnel, New Destiny Worship Center and any Good Samaritan that assisted with my accident/incident.
Signature (Required if medical evaluation, treatment and/or transport was refused)
Clear
If necessary to contact Parent/Guardian, please state TIME and HOW they were contacted
Describe Medical Treatment/First Aid
Check at least one church/school offical that has been notified of the Accident/Incident (THEY MUST HAVE BEEN PERSONALLY NOTIFIED BY YOU)
Choose an option
Date/Time they were notified
Form Submitter's Name
Form Submitter's Phone Number
Form Submitter's Email
Submit
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