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2. Date & Time of Incident*
   Date & Time of Incident

   Date & Time of Incident
3. Incident Location*
5. Description of Incident*
   Please describe the incident in detail here.
9. INVOLVED PARTY
11. Name
12. Age
13. Phone Number
15. Parent/Guardian Name (if under 18)
16. Parent/Guardian Phone Number
18. Address
20. Neighborhood
    -- Select One --Meadow ViewMountain ViewThe ArborsThe GrangeThe GrovesThe KnollsThe OaksThe OrchardThe TimbersThe VillageThe VineyardsThe Willows
21. Please check one*

    1. Victim
    2. Witness
    3. Offender
22. Victim of:

    1. Theft
    2. Vandalism
24. Items stolen or damaged
26. Was an injury sustained?*
    -- Select One --YesNo
27. If yes, describe the injury.
29. Did staff provide care?
    -- Select One --YesNo
30. If yes, please describe care provided.
34. INVOLVED PARTY (additional)
36. Name
    First and Last
37. Age
38. Phone Number
40. Parent/Guardian Name (if under 18)
41. Parent/Guardian Phone # (If under 18)
43. Address
45. Neighborhood
    -- Select One --Meadow ViewMountain ViewThe ArborsThe GrangeThe GrovesThe KnollsThe OaksThe OrchardThe TimbersThe VillageThe VineyardsThe Willows
46. Please check one

    1. Victim
    2. Witness
    3. Offender
47. Victim of:

    1. Theft
    2. Vandalism
49. Items stolen or damaged
51. Was injury sustained?
    -- Select One --YesNo
52. If yes, describe the injury.
54. Did staff provide care?
    -- Select One --YesNo
55. If yes, please describe care given.
59. Were emergency services called?*

    1. Yes
    2. No
60. If yes, which services were called?

    1. Police
    2. Fire Department
    3. Ambulance
62. Police or Emergency Officials Name
    First and Last
63. Report # (if applicable)
65. If yes, who called for services?
67. Signature*

    By checking the "I agree" box below, you agree and acknowledge that 1) your statement is true to the best of your knowledge, 2) by signing you authorize Power Ranch Community Association and its affiliates to file and report all information provided as necessary by law.

    1. I agree.
69. Electronic Signature
Leave This Blank:


75. 1. Receive an email copy of this form.
76. Email address

    This field is not part of the form submission.

77. Submit Submit and Print

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