Kayak Safety | Urban Kayaks

Use this form to submit information relative to your incident.

- Urban Kayaks Customer?
  Yes
  No
- If No, Outfitter Name?
  Waterriders, Kayak Chicago
- Customer / Paddler Name
- Customer Email
- Customer Phone
- Date of Incident
  Date Format: MM slash DD slash YYYY
- Product Start Time
  
  : HH
  
  MM
- UK Response Time
  
  : HH
  
  MM
- Paddle Tested
  Yes
  No
- If Yes, Tester Name. If No, Explain
- Jet Ski Operator
- Crossing Guard
- Manager on Duty
- Witness Statement
- Photo / Video of Incident
- Name
  This field is for validation purposes and should be left unchanged.