2025-462-E-DEAPR-Recreation Factory Partners-portsplex Management Agreement

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Care Provided Did facility staff provide care? Yes No Name of Person that provided care: _________________________________________ Describe in detail of care given: ___________________________________________ _____________________________________________________________________ _____________________________________________________________________ Was EMS called? Yes No If yes, by whom? ____________________________ Time EMS was called: _______________ AM PM Was the victim transported to a medical facility? Yes No If yes, where?_________________________________ If no, did the person return to activity? Yes No Victims signature (Parent/Guardian if victim is a minor) ______________________________________________________________________ Aquatics Only Number of Lifeguards at the time of incident: __________________________________ Number of Patron in the Pool area at the time of the incident: _____________________ What where the chemical levels in the pool? CL__________ PH___________ Name(s) of Lifeguard involved and on Duty: ___________________________________ _______________________________________________________________________ Report Prepared by: Name: __________________________________ Position: ________________________ Signature: _______________________________________________________________ Docusign Envelope ID: 177AA06A-30B4-42FF-A85A-78B5A7C51DBE