Carolina Mountain Club, Inc.
INCIDENT REPORT
PERSON COMPLETING REPORT: __________________________________________________________
SIGNATURE___________________________________________________________ DATE: ___________
ADDRESS: _____________________________________________________________________________
PHONES: (H) ____________________ (C)_______________________ (W)__________________________
CMC HIKE NUMBER AND/OR NAME_________________________________________________________
DATE OF INCIDENT: _______________ TIME: __________
LOCATION: _____________________________________________________________________________
DESCRIPTION OF INCIDENT: (PLEASE ATTACH ADDITIONAL PAGES AS NECESSARY) _____________
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PERSON CLAIMING INJURY OR DAMAGE
NAME: ________________________________________________ PHONE: ________________________
ADDRESS: ______________________________________________________________________________
IF INJURY, DESCRIBE: ____________________________________________________________________
IF PROPERTY, DESCRIBE: ________________________________________________________________
TAKEN TO HOSPITAL? ________________ MEANS OF TRANSPORT: ____ DOCTOR?______________
WITNESSES:
NAME: _______________________ ADDRESS: _________________________ PH: _________________
NAME: _______________________ ADDRESS: _________________________ PH: _________________
ANY GOV. OFFICIALS / EMS INVOLVED? ___________ TYPE:________________________________
ADDITIONAL COMMENTS, IF ANY ___________________________________________________________________
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After completing this form, please email a copy (or relevant information) to the current CMC President and then mail original to the Hike Scheduler as soon as possible.
Approved CMC Council 9. 2018