Fairfax County Neighborhood and Community Services
Athletic Services Division
12011 Government Center Parkway, Suite 1050
Fairfax, Virginia 22035-1115
Fax – 703-324-5649
athleticservices@fairfaxcounty.gov
Community groups are responsible for damages that occur during their recreation use of facilities. This
form must be completed for each incident. Damages during use by other groups not associated with NCS
are not your group’s responsibility, but if you are aware of any such damage, please complete as much of
this form as possible so the information may be made available to the proper officials. Please be specific
and thorough with your information. Mail, email, or fax this form to NCS.
Name of School: ___________________________________________________________________________
Date of Damage: ____________ Time of Damage__________________________
NCS responsible: Yes____ No____
Individual responsible for damage:
Name: _________________________________________ Phone: ___________________________________
Address: _________________________________________________________________________________
Witness to Damage:
Name: _________________________________________ Phone: ___________________________________
Address: _________________________________________________________________________________
Description of Damage: _____________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Location of damage:
__________________________________________________________________________________________
__________________________________________________________________________________________
Explain how damage occurred: ______________________________________________________________
__________________________________________________________________________________________
_________________________________________________________________________________________
If necessary, use reverse side for additional information.
___________________________________ ___________
Signature of Facility Director/NCS Staff Date
___________________________________ ___________
Signature of Custodian on Duty (Gym use only) Date
Revised 9/