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Gladstone
Nueva Vida
Oregon City
West Linn
Wilsonville
Cart
0
About Jesus
About New Life Church
Select A Campus
Join us in person
Gladstone
Nueva Vida
Oregon City
West Linn
Wilsonville
Notice of Injury
New Life Church >
Child Safety
Name
*
First Name
Last Name
Email
*
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
Other location
Details of Injury
Child's Name
*
First Name
Last Name
Date of Injury
*
MM
DD
YYYY
Time of Injury
*
Hour
Minute
Second
AM
PM
Where did the injury occur?
*
Full Description of Incident
*
Witnesses
Name - Person 1
*
First Name
Last Name
Phone - Person 1
*
(###)
###
####
Address - Person 1
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Name - Person 2
*
First Name
Last Name
Phone - Person 2
*
(###)
###
####
Address - Person 2
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
If Injury Requires Further Attention
Injured Child's Name
First Name
Last Name
Age
Name of Parent/Guardian
First Name
Last Name
Phone
(###)
###
####
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Injuries Sustained
Where was the injured child taken?
Hospital/doctor
Relationship to Organization
Member
Visitor
Student
If injury occurred on church premises, for what purpose was the injured on the premises?
Who was responsible for supervision at the time of the injury?
Does the injured have personal medical insurance that can apply?
Yes
No
If yes, what is the name of the medical insurance company?
Signature
*
First Name
Last Name
Date
*
MM
DD
YYYY
Thank you!
