Accident Report

Your name

required

Your email address

required

District Name

required

Laurel School District 7-70

Other

School Name - Out of District

required

School Name

required

South Elementary Principal: Katherine Dawe

Email: [email protected]

South Elementary Phone number: (406)628-3380

West Elementary Principal: Bethany Fuchs

Email: [email protected]

West Elementary Phone number: (406)628-3400

Graff Elementary Principal: Lynne Petersen

Email: [email protected]

Graff Elementary Phone number: (406)628-3450

Laurel Middle School Principal: Justin Klebe

Email: [email protected]

Laurel Middle School Phone number: (406)628-3900

Laurel Middle School Vice Principal: Allyson Robertus

Email: [email protected]

Laurel Middle School Phone number: (406)628-3900

Laurel High School Principal: Stacy Hall

Email: [email protected]

Laurel High School Phone number: (406)628-3500

Laurel High School Vice Principal: John Stilson

Email: [email protected]

Laurel High School Phone number: (406)628-3500

Principal's Name

required

School Phone

required

Date of Accident

required

Time of Accident

required

Supervising Employee Name

required

Claimant's First Name

required

Claimant's Middle Initial

Claimant's Last Name

required

Claimant's Address - City

Claimant's Address - State

Claimant's Address - Zip Code

Claimant's Social Security Number

Home Phone Number

Claimant's Age

Claimant's Date of Birth

Claimant's Sex

required

Male

Female

Claimant's Grade

required

Parent's Name (if student)

Parent's Work Phone Number

Describe accident and injury in detail (attach additional description as necessary)

required

Additional Description (optional)

Were efforts made to contact the parent/guardian about the accident?

required

Yes

Was first aid administered?

required

Yes

Who administered first aid?

Optional

Where was the student sent?

required

Home

To Physician

To Hospital

Staying at School

Is student covered by Student Accident Insurance?

Yes

If yes to the question above, please list Company Name, Address and Phone Number

If medical or hospital treatment was required, please complete the following information.

(Attach a copy of medical bills, if available.)

Name and address of doctor or hospital

Copy of medical bills

Witnesses

Name

Address

Phone

Signature of Person Completing the Report

required

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