Rec Center Patron Issue Report
Date
*
 /
Month
 /
Day
Year
Date Picker Icon
Time
Hour Minutes
AM
PM
AM/PM Option
Customer
*
First Name
Last Name
Name of person filling out this report
First Name
Last Name
Phone Number
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Staff
*
First Name
Last Name
Supervisor on duty
*
First Name
Last Name
What is customers appropriate age group?
Minor Parents/Guardian Present
Minor (under 18) without Parent/Guardian
Adult (18 and over)
Older Adult
Please check all that apply
Patron in Civic Rec
Patron has Day Pass
Patron has Monthly/Yearly Pass
Patron refused to give address or other information
Problem Behavior
Theft
Fighting
Inappropriate Language
Roughhousing or wrestling
Repeated Violation of Facility Rule
Harassment
Aggression to Staff
Aggression to Other Customers
Possession of Missing Property
Repeating Inappropriate Behavior
Illegal Gambling
Bullying
Threatening harm or violence
Rude to other customers
In Off Limited Area
Tobacco Violation
Other
Describe the incident with as much detail as possible
*
Observer 1
Location where incident occurred
*
Front Desk
Game Room
Hallway
Locker or Restroom room
Gym
Walking track
Weightroom
Cardio Area
Stairs
Foyer
Other
Consequence
*
Cool Down Period
Verbal Warning
Written Warning
One Day Suspension
Suspension with required meeting with management and guardian
Police Called
Length of Cool Down
Please Select
5 Minutes
10 Minutes
15 Minutes
20 Minutes
25 Minutes
30 Minutes
40 Minutes
50 Minutes
1 Hour
1+ Hour(s)
Notes in Account?
Please Select
Yes
No
Parent/guardian
full name of parent/guardian spoke with
Parent/Guardian Communication
Phone Call
Visited with Parent
Incident form Emailed
Management and Parent/Patron Meeting
Other
Additional Information from Parent/guardian contact
Police Action
Visited with Patron
Remove Patron
Arrested Patron
Need Follow up from P&R Mgmt
Other
Officer Name/ Badge #
Back
Next
Additional information
Signature of Patron
Signature of Parent/Guardian
Signature of On Duty Signature
Back
Submit
Submit
Next
Follow Up Information
Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Additional details: video locations, parent letter etc..
Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Previous Issues/Meetings
First Incident
Second Incident * Different Issue
Repeat Occurrence of Same Issue
Other
Meeting with
Adult Patron
Minor and Parent/Guardian
Parent/Guardian Only
Patron or Parent's Name Present
First Name
Last Name
Others present
First Name
Last Name
Management's Name
First Name
Last Name
Additional Staff present
First Name
Last Name
Action Taken
Patron can return with understanding of issue
One Week Suspension
One Month Suspension
One year suspension from Facility
Other
Return to Facility Date
Please Select
Follow up Meeting date
Please Select
Notes from Meeting
Patron Signature
Parent/Guardian signature
Parks and Recreation Management signature
Should be Empty: