Problem Location

Park*

Elm Avenue Henry Hudson Maple Ridge Moh-He-Con-Nuck Nature Preserve North Bethlehem Selkirk

South Bethlehem Firefighters Memorial Dog Normans Kill Ravines Rupert Road Fishing Access Colonial Acres

Date*

and time

problem observed

Type of Vandalism:*

Graffiti Broken Missing Debris/Garbage

Fire damage Grass/field damage by vehicle Landscape damage Other

Vandalism to*

Bench Sign Garbage receptacle Grass Landscaping Pavilion Bleachers Restroom Baseball/softball field Soccer field Playground Volleyball court

Fence Trees Parking area Roadway Picnic tables Flag Street hockey area (Elm Ave Park) Ice skating rink (Elm Ave Park) Fitness trail (Elm Ave Park) Fishing platform (Henry Hudson Park) Boat launch (Henry Hudson Park) Other

Were you a witness to the
vandalism?*

Yes

No

Has this been reported to the
Police Department (439-9973)?*

Yes

No

Brief Description (include exact
location within park)*

Photograph:

Your Information

Name:

Street Number and Name:

Address Line 2:

City:

State:

Zip Code:

Daytime Phone Number:

Email Address: