Information
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Incident Location Address ( The close business or intersections )
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Type Of Incident
- Fire Call
- Medical Call
- Police Assistant Call
- Public Service Call
- Vehicle Accident
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Date Of Incident
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Prepared by
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Surfside Beach Fire Personnel On The Incident
- Kevin Otte
- Prentice Williams
- Ted Sacra
- Larry Carter
- James Behrens
- Michael Miller
- Conor Clendein
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Additional Surfside Beach Fire Personnel On The Incident
Refusal Of Treatment And Transportation
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I, the undersigned, have been advised that medical assistance on my behalf is necessary and that refusal of said assistance and transportation may result in death or imperil my health. Nevertheless, I refuse to accept treatment or transportation and assume all risks and consequences of my decision and release the Surfside Beach Fire Department and the Town of Surfside Beach, with any personnel from any liability arising from my refusal.
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Signature Of Refusal
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Status Of Individual
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Signature Of Refusal
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Status Of Individual
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Signature Of Refusal
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Status Of Individual
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Signature Of Refusal
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Status Of Individual
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Signature Of Refusal
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Status Of Individual
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Signature Of Refusal
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Status Of Individual
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Signature Of Refusal
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Status Of Individual
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Signature Of Refusal
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Status Of Individual
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Signature Of Refusal
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Status Of Individual
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Signature Of Refusal
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Status Of Individual
Department Information
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Additional Comments
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Cad Number
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Surfside Beach Fire Apparatus
- Rescue 56
- Engine 56
- Engine 57
- Engine 58
- Tower 56
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Surfside Beach Fire Personnel SC Certification Number
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Fire / Rescue Representative's Signature And Printed Name
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Date Completed
