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The purpose of this form is to report accidents, injuries or behaviours that go against CityROCK's policies. This form should be completed less than 24 hours after the event. Any serious offences or crimes should be reported to the police. Staff are to please complete all fields below with as much information as possible.

Please select the appropriate category
AdultMinor
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First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Signature*
Parent or Guardian's Email Address

Email
A signed copy of this waiver will be sent to the email address you provide.
Date and time

Date of incident *

Time of incident *
Type of injury

Part of participants body injured or any damage from incident *

Severity of incident out of 10. 1 being a graze to 10 leaving on stretcher to the hospital. *
Account of events (staff to complete)

Describe how the incident happened with as much detail as possible *
Details - injured party
Member of CityROCK*
Yes
No
Did you have a spotter - bouldering related*
Yes
No
Top rope certified*
Yes
No
Lead certified*
Yes
No
Have you:*
Been through a safety orientation with a CityROCK staff member?
Watched the bouldering safety video?
Watched the top rope safety video?
Has your friend/partner/coach/teacher/other signed a novice supervision waiver with you?

Length of time climbing / belaying *

Area of climbing structures: *

Any additional things to note
Witness details

Witness Name and Surname *

Witness Contact Number *
Staff assisting with incident

Staff member Name and Surname: *

Manager on duty: *
Branch incident occurred *
Joburg
Cape Town
Action item
Staff to complete *
Call Cally if its more than a 5/10 - 082 453 8040
Call Robert (only if you cannot reach Cally) - 084 651 3219
Email incident report to Cally, Robert and Gym Managers or attach to cash up report
Attach waiver to incident report email
Camera footage if required

If severe and instructed by a manager or the patient agrees, important emergency contact numbers:
  • Netcare Paramedics (if they have medical aid) - 082 911
  • ER24 Paramedics (if they have medical aid) - 084 124 
  • CT Metro paramedics if no medical aid - 10177
Non- medical aid hospitals: 
  • JHB General Hospital: 011 488 4911
  • JHB Helen Joseph Hospital: 011 489 1011

  • CPT Groote Schuur: 021 404 9111


Medical aid hospitals:
  • JHB Netcare Olivedale Hospital: 011 301 0000

  • CPT Milnerton Mediclinic: 021 529 9000


  • Charles Edelstein (Medical advice): 083 859 8310



Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Relationship*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Signature*
Electronic Signature Consent - staff to sign*
 By signing this incident report, you agree that all information provided is correct and gathered to the best of your ability.


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