Fairfax County Neighborhood and Community Services
Athletic Services Division
12011 Government Center Parkway, Suite 1050
Fairfax, Virginia 22035-1115
Fax – 703-324-5546
athleticservices@fairfaxcounty.gov
Facility: ____________________Organization:____________________ Report for the period: _______________through:________________20________
In order to comply with NCS policies, the Facility Director, must check the facility for hazardous conditions and damage before and after use by
community groups. Groups are not responsible for damage that occurs other than during NCS assigned hours. If damage occurs during recreation hours,
the damage report must be sent to this office. The Facility Director is also required to record attendance information on this form. INSTRUCTIONS:
Fill out form daily! Please print. For gym use only, be sure the custodian signs the form. Use reverse side of this form for additional information if
necessary. Mail, email, or fax this form to NCS.
Day/Date
Begin
Insp.
Time
Brief descritipion of
damage to facility during
recreation hours (if do
damage, indicate so)
Final
Insp.
Time
Facility Director’s Signature Custodian’s Signature
(gym use only) Attendance Time of Usage
Beginning/Ending
Facility Director’s Name:__________________________Facility Director’s Signature:______________________________________Date:_______________