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2. 
3. Town of Castle Rock: Parks & Recreation Incident Report
   First Report of Incident. After submitting this form, staff are to print off and sign completed report and turn in hard copy to your supervisor.
5. Date/Time of Incident*
   Date/Time of Incident

   Date/Time of Incident
6. Was an injury reported?*

   1. Yes
   2. No
7. Was Police Notified?*

   1. Yes
   2. No
8. CRPD Report Number
10. Was EMS Notified?*

    1. Yes
    2. No
11. Emergency Contact Notified*

    1. Yes
    2. No
15. Injured/Affected Party
    This section is information identifying the injured/affected party.
17. Last Name*
18. First Name*
19. Date of Birth*
    Date of Birth
20. Gender*

    1. Male
    2. Female
22. Address*
24. City*
25. State*
26. Zip*
28. Phone #*
    xxx-xxx-xxxx
29. Email
33. Emergency Contact
    This section is information identifying the emergency contact of the injured/affected party.
35. Relationship to injured/affected party

    1. Parent/Guardian
    2. Spouse
    3. Other
36. Emergency Contact: Last Name
37. Emergency Contact: First Name
38. Emergency Contact Phone #
42. Side of Body Injured

    1. Left
    2. Right
43. Part of Body Injured

    1. Head
    2. Neck
    3. Chest
    4. Abdomen
    5. Hip
    6. Leg
    7. Knee

    1. Ankle
    2. Foot
    3. Toe
    4. Arm
    5. Elbow
    6. Wrist
    7. Finger
44. Other Injured Area:
48. Code

    1. Red: Fire
    2. Blue: Medical
    3. Yellow: Lockdown
    4. Grey: Weather

    1. White: Altercation
    2. Adam: Missing Child
    3. Black: Bomb Threat
49. Care Provided

    1. AED
    2. Backboard
    3. Bandage/Band-Aide
    4. CPR
    5. Ice

    1. Inline Stabilization
    2. O2
    3. Splint
    4. Water Rescue
    5. Advised to seek more advanced medical assistance
51. Detailed Description of the Incident and action/care taken by staff*
    Include any facts related to this incident and details of care provided. The system will not allow inappropriate language to be submitted. Please abbreviate where appropriate.
55. Incident Location
    Check all boxes that describe the area in which the incident took place.
56. Program Type*

    1. Adaptive Recreation
    2. Aquatic
    3. Athletics: Adult
    4. Athletics: Youth
    5. Fitness Programs

    1. Informal Recreation
    2. Instructional Programs: Adult
    3. Instructional Programs: Youth
    4. Rental/Birthday Party
    5. Special Event
58. Where did the incident take place?*

    1. Bison
    2. Butterfield
    3. Burgess
    4. Centennial
    5. Festival Park
    6. Founders
    7. Gemstone
    8. MAC
    9. Matney
    10. Metzler
    11. Paintbrush
    12. Philip S Miller Park
    13. Recreation Center
    14. Rhyolite
    15. School
    16. Other
59. School Facilities

    1. Castle Rock MS
    2. Mesa MS
    3. World Compass Academy
    4. Castle Rock Elementary
    5. Clear Sky
    6. Flag Stone
    7. Meadow View
    8. Renaissance
    9. Rock Ridge
    10. Sage Canyon
    11. Soaring Hawk
    12. South Ridge
60. Locker Room/Restroom

    1. Locker Room: Men
    2. Locker Room: Women
    3. Locker Room: Family
    4. Restroom: Men
    5. Restroom: Women
61. Athletic Venue

    1. Baseball
    2. Field: Grass
    3. Field: Turf
    4. Gymnasium
    5. Racquetball Court
    6. Skate Park
    7. Track
    8. Tennis Court
63. Aquatic Space

    1. Pool: Lap
    2. Pool: Leisure
    3. Pool: Toddler
    4. Pool: Vortex/Lazy River
    5. Play Structure/Feature
    6. Spa
    7. Splash Pad
    8. Steam Room
    9. Water Slide: Body
    10. Water Slide: Tube
    11. Water Slide: Toddler
64. Fitness Areas

    1. Fitness Area: Cardio
    2. Fitness Area: Free Weights
    3. Fitness Area: Selectorized
    4. Fitness Garage
    5. Fitness Studio
65. Event Venues

    1. Amphitheater
    2. Millhouse
    3. Pavilion
66. Rooms/Offices

    1. Classroom
    2. Corridor/Hallway
    3. Entrance
    4. Kitchen
    5. Lobby
    6. Office
    7. Panorama Hall
    8. Party Room
    9. Pottery Lab
    10. Senior Center
    11. Studio
    12. Tykes Toyland
68. Activity Areas

    1. Eye Play
    2. Play Structure
    3. Playground
    4. Trampoline
69. Other Description
73. Witness Information
    Please include information from witnesses of the incident.
75. First Name
76. Last Name
78. Email
79. Phone #
    xxx-xxx-xxxx
81. First Name
82. Last Name
84. Email
85. Phone #
    xxx-xxx-xxxx
89. Staff Completing this Form
91. First Name*
92. Last Name*
94. Staff Email*
95. Staff Phone#*
    xxx-xxx-xxxx
96. Hard Copy Signature/Date
    ___________________________________________
100. Supervisor
102. Supervisor Signature/Date
     ___________________________________________
Leave This Blank:


105. 1. Receive an email copy of this form.
106. Email address

     This field is not part of the form submission.

107. Submit

* indicates a required field