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About New Life Church
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Join us in person
Gladstone
Nueva Vida
Oregon City
West Linn
Wilsonville
Cart
0
About New Life Church
Select A Campus
Join us in person
Gladstone
Nueva Vida
Oregon City
West Linn
Wilsonville
Children’s Ministry Injury Report Form
Location
*
New Life Gladstone/Iglesia Nueva Vida, 6125 Caldwell Road, Gladstone, OR 97027
New Life Oregon City, 19077 South Beavercreek Road, Oregon City, OR 97045
New Life West Linn, 1984 McKillican Street, West Linn, OR 97068
New Life Wilsonville, 27960 Canyon Creek Road, Wilsonville, OR 97070
Other
If checked "Other," please note the address:
Child's Name
*
First Name
Last Name
Date of Injury
*
MM
DD
YYYY
Time of Injury
*
As close as possible.
Hour
Minute
Second
AM
PM
Full Description of Incident
*
Witness #1
First Name
Last Name
Phone
*
(###)
###
####
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Witness #2
*
First Name
Last Name
Phone
*
(###)
###
####
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Your Name
*
First Name
Last Name
Phone
*
(###)
###
####
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
If injury required further attention, continue below.
Child's name
First Name
Last Name
Date of Birth
MM
DD
YYYY
Parent/Guardians Name
First Name
Last Name
Phone
(###)
###
####
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Injuries Sustained
Where was injured taken?
Hospital or Doctor
Relationship to Organization
Member
Visitor
Student
If the injury occurred on church premises, for what purpose was the injured person on the premises?
Who was responsible for supervision at the time of injury?
Does the injured have personal medical insurance that can apply?
Yes
No
Name of Medical Insurance Company
Please include policy number if available
Your Name
First Name
Last Name
Date
MM
DD
YYYY
Thank you!
