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Bollinger Claim Form 2020-2023
In which student was involved when injured:
A. ■ Interscholastic Sports_________________________________________________________________________________________________________
B. ■ Cheerleading
■ Twirling or Flagwaving
■ Band Member
OR:
01 ■ Physical Ed. Class
04 ■ To and From School
02 ■ Classroom or Hallway
05 ■ Group Travel
03 ■ Playground (NOT Phys. Ed.) 06 ■ Non-School Activity (24 Hr. Plan)
Was School in Session? YES ■
NO ■
07 ■
08 ■
09 ■
Extra Curr. Activity ON Premises
Extra Curr....
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