Accident Report – Village of Holmen

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Parks & Recreation Dept.
(608) 526-2152
Cancellation Hotline:
(608) 526-6312

View Cancellations
Mike Brogan
Park & Recreation Director
(608) 526-6318
Chris Geary
Asst. Park & Recreation Director
(608) 526-6317
Alex Inglett
Asst. Park & Recreation Director
(608) 526-2152
Zak Kaatz
Parks Maintenance
Paul Servais
Parks Maintenance
Josh Rank
Parks Maintenance
Terry Long
Parks Maintenance
Aquatic Center Manager
Summer Only
(608) 526-6092
Fax: (608) 526-4357
421 S. Main St.
P.O. Box 158
Holmen, WI 54636
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Please complete the report below for any Park and Recreation related accidents that the department should be aware of. Non-Accidents/Injuries should be reported on our Incident Report.

This report will be emailed to Park & Recreation staff, upon sending. Staff at activity sites will also have paper forms if needed.

If you have any further information or questions, feel free to contact us at (608) 526-2152 (Mon. – Fri., 8am-4:30pm).

"*" indicates required fields

Name of Injured Person*

First Last

Date of Accident*

Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Sex*

Female

Male

Other

Age*

Approx. Time of Incident (Include AM or PM)*

State Exact Nature of Injury*

What was done with the injured person and by whose orders?*

Did a Park & Recreation Department employee witness the accident? If so, who?*

If not, where was/were the Department employee(s) when the accident occurred?

Witness Name

First Last

Witness Address

Street Address Address Line 2 City State ZIP Code

Witness Phone

Please give your opinion as to the cause of the accident, whether carelessness of the injured, carelessness of another, defective equipment, violation of safety rules, etc.

Anything else you'd like us to know?

Name of Person Filing Report*

First Last