notes Class notes Use the online form to submit your class [practice] notes to include on the weekly memo. Δ X/TwitterThis field is for validation purposes and should be left unchanged.FAMILY INFORMATIONFAMILY LAST NAME*CONTACT INFORMATIONRELATION TO INJURED*RELATION TO INJUREDCaregiverFatherFather's SpouseGuardianMotherMother's SpouseSelfNo RelationOtherOther Relation to Injured*CONTACT NAME* FIRST LAST CONTACT EMAIL* CONTACT PHONE*CONTACT ADDRESS STREET ADDRESS ADDRESS LINE 2 CITY STATEAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific STATE ZIP CODE INJURED PERSON INFORMATIONPARTICIPANT TYPE*PARTICIPANT TYPEWonder MemberMember Parent / GuardianTeam MemberEvent ParticipantEvent AttendantVolunteerGuestNAME* FIRST LAST GENDER*SELECTFemaleMaleBIRTHDATE* Month Day Year INCIDENT INFORMATIONPROGRAM/ACTIVITY OF INCIDENTPLEASE SELECT PROGRAM/ACTIVITYWonder Homeschool Day (HSD)Wonder Community Time (CT)A Wonder Conference or Speaking EventOtherOTHER WONDER-RELATED EVENT*DATE OF INCIDENT* Month Day Year TIME OF INCIDENT (IF KNOWN) : Hours Minutes AM PM AM/PM BLOCK OF INCIDENT* Before Wonder Program Started Assembly BLOCK 1 (10:00 - 11:30) BLOCK 2 (11:30 - 1:00) LUNCH (1:00 - 1:30) BLOCK 3 (1:30 - 2:30) BLOCK 4 (2:30 - 3:30) BLOCK 5 (3:30 - 4:30) DINNER (4:30-5:30) Interval After Wonder Program Ended CLASS OF INCIDENT* Open Gym Social Hall Study Hall Playroom Little Movers (Infant - 3y) Little Shakers (3y - 5y) Mini Music (5y - 7y) Mini Art (4y - 7y) Discovery Bookworms Music Foundations Prelude Orchestra Prelude Band Youth Orchestra Youth Band Beginning Instrument Class Recorder Art 101 Art 101X Dance 101 Dance 101X Prime Choir (7y - 12y) Junior Choir (12y - 14y) Senior Choir (14y+) Theater LOCATION OF INCIDENT (CHECK ALL THAT APPLY)* Auditorium Athletic Field Bus Cafeteria Classroom Corridor Gymnasium Hallway Parking Lot Playground Outdoor Play Area Restroom Stairway Vocation Shop/Lab Other OTHER LOCATION*SURFACE OF INCIDENT (CHECK ALL THAT APPLY)* Asphalt Carpet Concrete Dirt Gravel Gymnasium Floor Ice/Snow Lawn/Grass Mat Sand Synthetic Surface Tile Wood Chips/Mulch Other OTHER SURFACE (EXPLAIN)*EQUIPMENT USE* No equipment involved NATURE OF INJURY (CHECK ALL THAT APPLY)* New Injury Recurrent Injury Aggravated Injury Other OTHER NATURE OF INJURY*SYMPTOMS OF INJURY (CHECK ALL THAT APPLY)* Abrasion Amputation Asphyxiation Asthma Bite Blisters Bone Fracture / Break (Suspected) Bruise / Contusion Burn Cardiac Problem Concussion / Head Injury Cramp Cut / Graze Dislocation Electrical Shock Headache High Temperature Inflammation / Swelling Insect Bite / Sting Laceration Loss of Consciousness Nausea Poisoning Puncture Respiratory Problem Scalds Scratches Shock Spinal Injury Sprain Vomiting OTHER SYMPTOMS OF INJURY*PART OF BODY INJURED (CHECK ALL THAT APPLY)* Abdomen Ankle Arm Back Chest/Ribs Chin Collarbone Ear Elbow Eye Face Foot / Toe Hand / Finger Head Hip / Pelvis Knee Leg Mouth / Lip Neck / Throat Nose Pelvis Scalp Shoulder Tooth / Teeth Wrist IMMEDIATE ACTION (CHECK ALL THAT APPLY)* No Treatment Required First-Aid Treatment CPR Crutches Dressing IPE Pen Massage RICER Sling/splint Strapping Stretching Called Parent / Guardian Went to Nurse Went Home Went to Physician Went to Hospital Other OTHER IMMEDIATE ACTION*FOLLOW UP ACTION (CHECK ALL THAT APPLY)* None Ambulance Hospital Other OTHER FOLLOW UP ACTION*Was 911 called?* Yes No Hospital Name*Was the injured taken to the hospital by ambulance or emergency vehicle?* Yes No Physician Name* First Last WITNESSES*Please list any witnesses you can think of. Use the (+) to add more witnesses. Don't worry about exact spelling of names. You can list the full name of the witness or just first or last name. If you don't remember the name of a witness, just describe the witness as best as you can. PLEASE DESCRIBE WHAT HAPPENED IN YOUR OWN WORDS*INSURANCE INFORMATIONDoes the injured person have primary insurance?* Yes No Insurance Company Name*Insurance Company Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Policy Number*ID#*Certification* I hereby certify that, to the best of my knowledge, the provided information is true and accurate.*CONTACT NAME* FIRST LAST Signature*
