Skatepark Incident / Injury Report
2nd Nature Park · Peekskill, NY · Liability / Insurance Record
⚠ Complete
within 24 hours
of the incident. Retain on file
7 years
per general liability standard. Have the skater (or guardian, if minor) sign before they leave the park.
Incident details
Date of incident
Time
Park area
— Select —
Street section
Bowl / deep end
Mini ramp
Snake run
Beginner / flat area
Lobby / front desk
Restrooms
Parking lot
Outside park
Other
Lighting / conditions
Normal
Crowded session
Wet / slippery surface
Equipment in transit
Other
Specific spot (if applicable)
Injured skater
Skater name
Date of birth
Age
Skill level
First time
Beginner
Intermediate
Advanced
Pro / sponsored
Phone
Pass / status
Day pass
Punch card
Monthly member
Annual member
Lesson student
Birthday party guest
Comped / industry
Waiver on file?
YES — on file (Smartwaiver)
YES — paper waiver attached
NO — investigate why
Helmet worn?
Yes — own helmet
Yes — rented from us
No
Helmet was provided but not worn correctly
Parent / Guardian (if skater is under 18)
Guardian name
Relationship
Guardian phone
Guardian on-site at incident?
Yes
No
Time guardian was contacted
Type of incident (check all that apply)
Fall / slam
Collision (skater-skater)
Cut / scrape / road rash
Possible fracture / sprain
Head impact
Loss of consciousness
Near miss (no injury)
Equipment failure (board, ramp, rental)
Medical event (seizure, asthma, allergic reaction, etc.)
Altercation / fight
Theft / lost property
Property damage (park or skater's gear)
Other (describe below)
Body part injured (if applicable)
Equipment involved
Description — what happened?
Medical treatment
No treatment needed (skater walked away)
First aid on site (bandage, ice, etc.)
Skater rested, sat out remainder of session
Parent took to urgent care / doctor
Sent to ER / hospital
911 called / EMS responded
Hospital / urgent care name
EMS arrival time (if 911 called)
Witnesses
Witness 1 — Name & phone
Witness 2 — Name & phone
Staff member who responded
Corrective action
What will be done to prevent this from happening again?
Action owner
Action deadline
Photos / evidence
Attach photos of the location, injury (with skater/guardian permission), and damaged equipment. Stored locally on the staff device — do not upload anywhere without parent consent if minor.
Signatures
Skater (or guardian if minor):
Date:
Print name:
Staff who completed report:
Date:
Owner / manager review:
Date:
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