Accident Report

Mailing Address: 364 Bateman Road, Barrington, IL 60010

Phone: 847-783-6772

Please complete this form for instances of accident in which a person is injured. Please notify the Barrington Hills Park District Office by phone in case of accident reports. You may mail in this form, fax, or put in District mail box at the Riding Center.

Location of Accident

Full Name of Injured Person

PrefixFirst NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Area CodePhone Number

E-mail

Age of Injured Person

Apparent Injury:

Persons Notified:

Injured Person:

Was the injured transported?

If the injured was transported, by whom?

Was First Aid Administered?

Who administered First Aid?

Were Paramedics Called?

If yes, who called the paramedics?

Description and Narrative of Accident:

Name of Event or Group Injured associated:

Witness:

Park District Notified by Telephone:

Submitted By:

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