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Injury or Health Incident Report
Please provide as much information & detail as possible in the report below. If multiple parties were injured, please fill out a separate form for each party.
What information do I need?
First name:
Last name:
Connection to North Bay:
Guest/Attender
Staff
Volunteer
No Connection
Sex:
Male
Female
Age:
Phone number:
Email:
Does the injured party have medical insurance?
Yes
No
Policy holder:
Insurance company:
Policy #:
Insurance contact #:
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