Name: *

First Name

Last Name

Is the person submitting this report a witness to the incident? *

Yes, I personally witnessed the incident

No, I did not personally witness the incident

Date of incident occurrence: *

MM

DD

YYYY

Time of incident occurrence: *

Hour

Minute

Second

AM PM

Name of injured individual: *

First Name

Last Name

Contact number of injured individual:

(###)

###

####

Is the injured individual a: *

RBR member

MHF student

Student of another trainer

RBR boarder

Leasee

RBR guest

Other (Please describe below)

Is the injured individual a minor? *

Yes, they are under 18 years of age

No, they are over 18 years of age

Emergency contact of injured individual / name of legal guardian or parent (if applicable):

First Name

Last Name

Where did this incident occur? *

Lower tack up area

Upper tack up area

Round pen

Oval arena

Main arena

Lower arena

Parking area

Other (Please describe below)

Was the injury witnessed? *

Yes

No

Is the witness an RBR member or club guest? *

Yes

No

Not sure

Was 911 called? *

Yes

No

Were any of the following required: *

Paramedics/ambulance

Emergency room visit

Hospitalization

Not applicable

Other

Was there damage to the facility or any equipment? *

Yes

No

Not sure