Please complete this form only if it's an emergency, if you want to validate your SEVIS status please click here

Program Name:

Please Select Global Teens Youth Ambassadors Leaders Club Alternative Spring Break Intern/Trainees ELESAIR 14th Street ELESAIR Offsite Bronx Y NAWC Chinatown Y NAWC Flushing Y NAWC Harlem Y NAWC PPK Y NAWC Staten Island Y NAWC

First Name *

Last Name *

Date of Birth
(mm/dd/yyyy)

SEVIS #

Incident Name

Emergency *

Incident Date *
(mm/dd/yyyy)

Incident Time

Yes   No

Incident Details: (factual information only, include witness name and contact information)

OTHER NOTES OR IMPORTANT INFORMATION

Full Name of Person filling out this form *

Phone Number where you can be reached *

Nature of Incident

Location of Incident

Please Select Injury Harassment Death Other

Please Select Host Site Home Main Site Off-site

Host Site Name

Did incident happen at Participants Work Site?

Yes   No

Site Address

Insurance Coverage for Participant

Other Insurance
(please provide insurance carrier, policy number, contact information, etc)

please select Insurance through YMCA Other

Did Participant go to the Hospital? *

EMS Called

Yes   No

Yes   No

Workers Comp Notified

New Incident *

Yes   No

Yes   No

* Required Field

Please review information before clicking Submit