GSGLA Accident/Incident Report Accident/Incident report forms are submitted when an incident or accident occurs. For incidents occurring after hours, "Emergency After Hours Call Card" (Pink Card). Girl Scouts of Greater Los Angeles Emergency Phone # 1-877-423-4752 Please submit ONE report within 72 hours of the incidentContact InformationName of adult directing activity:* First Last Title:* Phone:*Email* Enter Email Confirm Email Service Unit*400 Rancho Foothills401 Alhambra/Rosemead/Santa Fe Trails402 Bonita403 Claremont404 Anita Oaks/Mission Camellias405 Chino406 Canon Trails407 CV/Glendale408 Pomona409 River Trails411 Upland412 La Canada414 Monrovia/Duarte415 Las Caballeras416 Puente Hills418 San Marino419 Glendora420 South Pasadena421 Covina Oaks422 West Covina425 Crown Poppy426 Mt. View427 Campo Verde428 Ontario/Montclair429 Gateway450 Chino Hills501 Compton/Lynwood502 Bellflower/Hollymount503 Belmont504 Lachen505 Holly Hills506 Highland Rose507 Lakewood508 Alamitos/Marina509 Westchester/Del Rey511 Culver City512 RDE/Sil-Dom513 Northeast Hills515 El Segundo516 East LA517 Southwest SU518 Center City519 Lawthornes522 La Brea Heights524 King Harbor526 North Redondo528 Manhattan Beach529 South Bay Four533 Marina538 Pali/Mali540 San Pedro542 Santa Monica Bay543 S. Torrance545 Torrance546 PV/Penn601 Burbank604 Westside605 Rancho Calabasas606 Las Virgenes608 Palmdale/Acton/Agua Dulce612 Golden Savannahs616 Canyon Star617 Sagebrush624 Woodland Hills636 Kern640 Mission Rose641 Twin Oaks642 Heart of the Valley643 Stoneyridge644 Magnolia647 Lancaster649 Coyote Canyon650 North RiverHiddenTroop/group Number:* Troop/group Number:* eSignature of adult directing activity:* Incident InformationDate of Emergency:* MM slash DD slash YYYY Time am/pm:* Date of report:* MM slash DD slash YYYY Did the incident take place on GSGLA property?* Yes No Name/Address of GSGLA Property Incident Occurred:* Name/Address of Location Incident Occurred:* Was anyone injured?* Yes No Incident Description:*Describe in detail events leading to injury/incident and what you did. Were medical advice and/or emergency transport required?Was this a GSGLA camp property?* Yes No Which camp?*Camp Lakota - Frazier ParkEl Ranchito - Long BeachLa Casita - ClaremontMarine Landing - Long BeachMariposa - AltadenaOtherPlease describe:* Were the police contacted?* Yes No Was a police report filed?* Yes No Were there any witnesses?* Yes No Injury InformationHow many people were injured?*12345More than 5First Injured Person's InformationName of Injured Person:* First Last Date of Birth:* MM slash DD slash YYYY Age:* Phone Number:*Email:* Enter Email Confirm Email Service Unit*- Please Select One -SU400 Rancho FoothillsSU401 Alhambra/Rosemead/SFTSU402 BonitaSU403 ClaremontSU404 Anita Oaks/Mission CamelliasSU405 ChinoSU406 Canon Trails/Rio HondoSU407 CV/GlendaleSU408 PomonaSU409 River TrailsSU411 UplandSU412 La CanadaSU414 Monrovia/DuarteSU415 Las CaballerasSU416 Puente HillsSU418 San MarinoSU419 GlendoraSU420 South PasadenaSU421 Covina OaksSU422 West CovinaSU425 Crown PoppySU426 Mountain ViewSU427 Campo VerdeSU428 Ontario/MontclairSU429 GatewaySU450 Las ColinasSU501 Compton/LynwoodSU502 Bellfower/HollymountSU503 BelmontSU504 LachenSU505 Holly HillsSU506 New Holly HillsSU507 LakewoodSU508 Alamitos/MarinaSU509 Westchester/Del ReySU511 Culver CitySU512 RDE/Sil-DomSU513 Northeast Hills/ East LASU514 Center CitySU515 El SegundoSU516 East LASU517 SoutheastSU518 Center CitySU519 LawnthornesSU522 La Brea HeightsSU524 King HarborSU526 North Redondo BeachSU528 Manhattan BeachSU529 South Bay FourSU533 MarinaSU538 Palisades/MalibuSU540 San PedroSU542 Santa Monica BaySU543 South TorranceSU544 TorranceSU545 North TorranceSU546 PV/PennSU601 BurbankSU604 WestsideSU605 Rancho CalabasasSU606 Las VirgenesSU608 Palmdale/Acton/Aqua DulceSU612 Golden SavannahSU616 Canyon StarSU617 SagebrushSU624 Woodland HillsSU636 KernSU640 Mission ValleySU641 Twin OaksSU642 Heart of the ValleySU643 StoneyridgeSU644 MagnoliaSU645 SummitroseSU647 LancasterSU649 Coyote CanyonSU650 North RiverUnsure or N/ATroop Number:* Complete Address:* Street Address 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 Nature and extent of injury:*Name of attending medical professional:* First Last Title of attending medical professional:* Treatment given:*Name of Hospital:* City/Location:* Hospital Phone:*Second Injured Person's InformationName of Injured Person:* First Last Date of Birth:* MM slash DD slash YYYY Age:* Phone Number:*Email:* Enter Email Confirm Email Service Unit*- Please Select One -400 Rancho Foothills401 Alhambra/Rosemead/Santa Fe Trails402 Bonita403 Claremont404 Anita Oaks/Mission Camellias405 Chino406 Canon Trails407 CV/Glendale408 Pomona409 River Trails411 Upland412 La Canada414 Monrovia/Duarte415 Las Caballeras416 Puente Hills418 San Marino419 Glendora420 South Pasadena421 Covina Oaks422 West Covina425 Crown Poppy426 Mt. View427 Campo Verde428 Ontario/Montclair429 Gateway450 Chino Hills501 Compton/Lynwood502 Bellflower/Hollymount503 Belmont504 Lachen505 Holly Hills506 Highland Rose507 Lakewood508 Alamitos/Marina509 Westchester/Del Rey511 Culver City512 RDE/Sil-Dom513 Northeast Hills515 El Segundo516 East LA517 Southwest SU518 Center City519 Lawthornes522 La Brea Heights524 King Harbor526 North Redondo528 Manhattan Beach529 South Bay Four533 Marina538 Pali/Mali540 San Pedro542 Santa Monica Bay543 S. Torrance545 Torrance546 PV/Penn601 Burbank604 Westside606 Las Virgenes608 Palmdale/Acton/Agua Dulce612 Golden Savannahs616 Canyon Star617 Sagebrush624 Woodland Hills636 Kern640 Mission Rose641 Twin Oaks642 Heart of the Valley643 Stoneyridge644 Magnolia649 Coyote Canyon650 North RiverTroop Number:* Complete Address:* Street Address 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 Nature and extent of injury:*Name of attending medical professional:* First Last Title of attending medical professional:* Treatment given:*Name of Hospital:* City/Location:* Hospital Phone:*Third Injured Person's InformationName of Injured Person:* First Last Date of Birth:* MM slash DD slash YYYY Age:* Phone Number:*Email:* Enter Email Confirm Email Service Unit*- Please Select One -400 Rancho Foothills401 Alhambra/Rosemead/Santa Fe Trails402 Bonita403 Claremont404 Anita Oaks/Mission Camellias405 Chino406 Canon Trails407 CV/Glendale408 Pomona409 River Trails411 Upland412 La Canada414 Monrovia/Duarte415 Las Caballeras416 Puente Hills418 San Marino419 Glendora420 South Pasadena421 Covina Oaks422 West Covina425 Crown Poppy426 Mt. View427 Campo Verde428 Ontario/Montclair429 Gateway450 Chino Hills501 Compton/Lynwood502 Bellflower/Hollymount503 Belmont504 Lachen505 Holly Hills506 Highland Rose507 Lakewood508 Alamitos/Marina509 Westchester/Del Rey511 Culver City512 RDE/Sil-Dom513 Northeast Hills515 El Segundo516 East LA517 Southwest SU518 Center City519 Lawthornes522 La Brea Heights524 King Harbor526 North Redondo528 Manhattan Beach529 South Bay Four533 Marina538 Pali/Mali540 San Pedro542 Santa Monica Bay543 S. Torrance545 Torrance546 PV/Penn601 Burbank604 Westside606 Las Virgenes608 Palmdale/Acton/Agua Dulce612 Golden Savannahs616 Canyon Star617 Sagebrush624 Woodland Hills636 Kern640 Mission Rose641 Twin Oaks642 Heart of the Valley643 Stoneyridge644 Magnolia649 Coyote Canyon650 North RiverTroop Number:* Complete Address:* Street Address 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 Nature and extent of injury:*Name of attending medical professional:* First Last Title of attending medical professional:* Treatment given:*Name of Hospital:* City/Location:* Hospital Phone:*Fourth Injured Person's InformationName of Injured Person:* First Last Date of Birth:* MM slash DD slash YYYY Age:* Phone Number:*Email:* Enter Email Confirm Email Service Unit*- Please Select One -400 Rancho Foothills401 Alhambra/Rosemead/Santa Fe Trails402 Bonita403 Claremont404 Anita Oaks/Mission Camellias405 Chino406 Canon Trails407 CV/Glendale408 Pomona409 River Trails411 Upland412 La Canada414 Monrovia/Duarte415 Las Caballeras416 Puente Hills418 San Marino419 Glendora420 South Pasadena421 Covina Oaks422 West Covina425 Crown Poppy426 Mt. View427 Campo Verde428 Ontario/Montclair429 Gateway450 Chino Hills501 Compton/Lynwood502 Bellflower/Hollymount503 Belmont504 Lachen505 Holly Hills506 Highland Rose507 Lakewood508 Alamitos/Marina509 Westchester/Del Rey511 Culver City512 RDE/Sil-Dom513 Northeast Hills515 El Segundo516 East LA517 Southwest SU518 Center City519 Lawthornes522 La Brea Heights524 King Harbor526 North Redondo528 Manhattan Beach529 South Bay Four533 Marina538 Pali/Mali540 San Pedro542 Santa Monica Bay543 S. Torrance545 Torrance546 PV/Penn601 Burbank604 Westside606 Las Virgenes608 Palmdale/Acton/Agua Dulce612 Golden Savannahs616 Canyon Star617 Sagebrush624 Woodland Hills636 Kern640 Mission Rose641 Twin Oaks642 Heart of the Valley643 Stoneyridge644 Magnolia649 Coyote Canyon650 North RiverTroop Number:* Complete Address:* Street Address 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 Nature and extent of injury:*Name of attending medical professional:* First Last Title of attending medical professional:* Treatment given:*Name of Hospital:* City/Location:* Hospital Phone:*Fifth Injured Person's InformationName of Injured Person:* First Last Date of Birth:* MM slash DD slash YYYY Age:* Phone Number:*Email:* Enter Email Confirm Email Service Unit*- Please Select One -400 Rancho Foothills401 Alhambra/Rosemead/Santa Fe Trails402 Bonita403 Claremont404 Anita Oaks/Mission Camellias405 Chino406 Canon Trails407 CV/Glendale408 Pomona409 River Trails411 Upland412 La Canada414 Monrovia/Duarte415 Las Caballeras416 Puente Hills418 San Marino419 Glendora420 South Pasadena421 Covina Oaks422 West Covina425 Crown Poppy426 Mt. View427 Campo Verde428 Ontario/Montclair429 Gateway450 Chino Hills501 Compton/Lynwood502 Bellflower/Hollymount503 Belmont504 Lachen505 Holly Hills506 Highland Rose507 Lakewood508 Alamitos/Marina509 Westchester/Del Rey511 Culver City512 RDE/Sil-Dom513 Northeast Hills515 El Segundo516 East LA517 Southwest SU518 Center City519 Lawthornes522 La Brea Heights524 King Harbor526 North Redondo528 Manhattan Beach529 South Bay Four533 Marina538 Pali/Mali540 San Pedro542 Santa Monica Bay543 S. Torrance545 Torrance546 PV/Penn601 Burbank604 Westside606 Las Virgenes608 Palmdale/Acton/Agua Dulce612 Golden Savannahs616 Canyon Star617 Sagebrush624 Woodland Hills636 Kern640 Mission Rose641 Twin Oaks642 Heart of the Valley643 Stoneyridge644 Magnolia649 Coyote Canyon650 North RiverTroop Number:* Complete Address:* Street Address 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 Nature and extent of injury:*Name of attending medical professional:* First Last Title of attending medical professional:* Treatment given:*Name of Hospital:* City/Location:* Hospital Phone:*Additional injured parties:*For injured persons in addition to the five listed above, please upload a document (pdf or word) containing the information above for each person.Accepted file types: pdf, doc, Max. file size: 50 MB.Witnesses:How many witnesses?*OneTwoThreeName #1:* First Last Phone #1:*Address #1:* Street Address 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 Name #2:* First Last Phone #2:*Address #2:* Street Address 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 Name #3:* First Last Phone #3:*Address #3:* Street Address 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 Additional InformationAdditional Information:Captcha