Please print and fill out this form, then hand deliver to the VP of Academic and Community Affairs: 524-3207, or mail to:
Lakes Region community College
379 Belmont Road
Laconia, NH 03246
Attention: VP Academic and Community Affairs
The Following Personal Information is Optional:
Name: _________________________________________________
Home Phone: ______________________________________________
Address: _________________________________________________
City: ____________________________________________________
State: ___________________________________________________
Zip Code: _______________
E-mail: __________________________________________________
Incident Information:
Date & Time Incident Occured: _________________________________________
Location Incident Occured: ___________________________________________________
Description of Incident (Please be as complete and detailed as possible):
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