Middle Kingdom Chirurgeon Event Report

THIS REPORT GOES TO
Constellation Regional    Midlands Regional    Oaken Regional    Pentamere Regional


CONTACT INFO
SCA Name:
Legal Name:
Street Address:
City, State, Zip:
Phone:
Email Address: (A copy of this report will be emailed to your email address)
SCA Membership #:
SCA Membership Expiration:


EVENT INFORMATION
Event Name:
Event Date:
Event Location:
Marshal In Charge:
Chirurgeon In Charge:
Event Attendees:
Number of Heavy Fighters:
Number of Rapier Fighters:
Weather and Conditions:


WARRANTED CHIRURGEONS

Name Home Group


CHIRURGEONS-IN-TRAINING OBSERVED
(Be sure to submit Chirurgeon-in-Training evaluations after submitting this form)

Name Home Group


INJURIES

NO INJURIES (Really, nothing happened)

MINIMAL INJURIES (Treated on-site, unlikely to need medical followup)
  Heavy Rapier Kitchen Camping Dancing Bystander Other
# Band-Aids
Over-the-Counter Meds
Mild Heat Injury:
Contusions/Abrasions:
Musculoskeletal:
Burns:
Splinters/FB:
Substance Abuse
Other

MODERATE INJURIES (Treated on-site and requiring medical follow-up)
  Heavy Rapier Kitchen Camping Dancing Bystander Other
Fractures
Dislocations
Lacerations:
Unconsciousness
Burns:
Environmental
Medical
Substance Abuse
Other

SERIOUS INJURIES Injuries requiring immediate transport and treatment and/or treatment of minors
No Serious Injuries
There were Serious Injuries. An Incident Report has been filled out and will be submitted separately

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