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KIDS CITY HAWAII
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HONOLULU
Guest Accident/ Incident Report
INFORMATION ABOUT PERSON INVOLVED IN THE INCIDENT
Full Name
Birthdate (MM/DD/YY)
Gender
Male
Female
Booking ID
Waiver Attached
Yes
No
Were you wearing socks?
Grip Socks
Regular Socks
Barefeet
INFORMATION ABOUT THE INCIDENT
Date of Incident (MM/DD/YY)
Time of Incident (example 13:00)
Location of Incident
Equipment involved in the incident
Cause of the Incident
Body part affected as a result of the Injury
Information about any administered treatment given
Full description of the Incident (What happened, how it happened, factors leading to the event, etc.) Please be as specific as possible {attach additional sheets if necessary}
Medical Attention
Yes
No
Police Notified
Yes
No
Were there any witnesses to the incident?
Yes
No
ANSWER IF THE PERSON INVOLVED WITH THE INCIDENT IS A MINOR
Were parent/s or guardian notified?
Yes
No
Full Name of parent/s or guardian
Phone Number of parent/s or guardian
Did this incident happen during parent/s or guardian supervision?
Yes
No
If YES, what was their first reaction?
If NO, where were they?
Other comment if any:
MANAGER / SUPERVISOR ON DUTY
Full Name
Position
Compensation if any:
Other comment if any:
Witness Signature : By signing this, I have told everything based on the facts and understand that giving false information can disadvantage and worsen the situation.
Clear
Submit Report
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