This form should only be used if there is a serious incident that involved the use of a missile weapon (bow/ crossbow/arrows, etc). Keep a copy for your files and send one to the DSMCA within two days of the incident.

Group Name: ________________________________

Date of Event: _______________________________

Submitted By: _______________________________

Society Name

______________________________

Mundane Name

Address: ___________________________________

City, State, Zip: ______________________________

Phone Number: ______________________________

E-mail: _____________________________________

Event Name: ________________________________

Event Location: ______________________________

Site Marshal: _______________________________

Society Name

_______________________________

 Person(s) Involved: __________________________

Society Name

__________________________

Address: ________________________________

City, State, Zip: ___________________________

Birthday: ________________________________

Phone Number: ___________________________