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Thank you for an amazing COVID-free summer!
Click here to learn more about the 2021 season
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Virtual Home Visit
ATTEND A
Virtual Open House
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Why Camp Sequoia?
Mission & Approach
Who We Serve
Our Team
Facilities
Virtual Tour
Health & Safety
Dining Services
FAQs
Alumni
What’s New
Programs
Summer Camp
School Year Trips
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Get Started
ACA Incident/Accident Report Form
Camp Name: Camp Sequoia
Address: 200 Seminary St, Pennsbrug PA 18073
Date of Report
*
MM
DD
YYYY
Person Involved was a:
*
Camper
Staff
Visitor
Sex of Person Involved:
*
Male
Female
Name of Person Involved
*
List the Primary Person Involved in Accident/Incident
First
Last
Name of Parent/Guardian (if minor was involved)
Phone Number of Parent/Guardian?
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Names of Witnesses
*
Please list staff/campers involved in incident (add lines for each witness by hitting + symbol to the right)
Type of Incident
*
Behavioral
Accident
Epidemic/Illness
Other (please describe)
Describe "other" selection:
Date of Incident
*
MM
DD
YYYY
Time of Incident
*
:
HH
MM
AM
PM
Describe the sequence of activity in detail including what the (injured) person was doing at the time:
*
Where did the incident occur?
*
Dorm Room
Kriebel
Gaga Pits
Schultz
Big Gym
Blue Gym
Pool
Middle School
Outside (field activity)
Dining Hall
Lounge
Nurses Office
Ruhl
Weight Room
Library
Other
Describe "other" selection:
Kriebel Floor:
Was injured participating in activity at time of injury/incident?
*
Yes
No
If so, what activity?
Any equipment involved in injury/incident/accident?
*
Yes
No
What equipment?
What could the injured have done to prevent injury?
*
Emergency Procedures followed at time of incident/accident?
*
(Please include who conducted the emergency procedures)
Submitted by:
*
First
Last
Phone
*
Please list the phone number of the submitter
Position
*
Division Head
SST Member
Deputy Division Head
Activity/Program Specialist
Counselor
Director
Associate Director
Nurse
Lifeguard
Night Security Team Member
Other
Please list "other" position:
CAPTCHA