Injury Reporting Form – New Jersey Youth Hockey League

Injured Person's Name *

First

Last

Injured Person's Date of Birth *

Parent/Guardian Name (if Injured Person is a Minor)

First

Last

Parent/Guardian Phone *

Parent/Guardian Email *

Injured Person's Home Address *

Address Line 1

Address Line 2

City

State

Zip Code

Date & Time of Incident *

Date

Time

Injured Person's Club Affiliation *

Injured Person's Team Level *

Facility where Injury Occurred *

Detailed Description of Incident *

Actions Taken/Intervention (EMT/ambulance called, ice applied, bandage applied, etc.) *

Post-Injury Actions *