Name-- Last:________________ First:________________ Age:_______

Date:_________________ Location:___________________

Where did the injury take place:___________________________________________________

When did the injury take place:____________________________________________________

How did the injury occur:_________________________________________________________

Where was the injury(part of body):_________________________________________________

Was it a head/neck injury:________________________________________________________

Was the injured player unconscious:________________________________________________

Was the hit/slash illegal:__________________________________________________________

Was the injured player wearing equipment:___________________________________________

Was the equipment altered/doctored:________________________________________________

Were all straps and buckets properly fastened:________________________________________

Did the injury player hit the boards/ground:___________________________________________

Did the injured player hit the net:___________________________________________________

Was the injury from fisticuffs:______________________________________________________

Was the hit intentional:___________________________________________________________

Was the game meanful:__________________________________________________________

Did the non-injured player need the ball:_____________________________________________

Was dangerous equipment being worn by the players:__________________________________

Was the injured player bleeding:___________________________________________________

Was the injured player vomiting:____________________________________________________

Were there any broken/chipped/fractured bones:_______________________________________

Was the injury a result of a lossie:__________________________________________________

Could the injured player continue to play:_____________________________________________

How much medical treatment was needed:___________________________________________

Was the ambulance needed/called:_________________________________________________

Was the game chippy/dirty:_______________________________________________________

Was that part of the players body all ready hurt:_______________________________________

What was the score when the injury occurred:_________________________________________

Was it late in the game:__________________________________________________________

Injured Player:________________________________________(signature)

Non-Injured Player:____________________________________(signature)

Official:_____________________________________________ (signature if available)

All injury forms must be fully filled out/signed by players/officials.

Forms will be sent to MILL Front Office.

Play will go under review by Board of Governors