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Injury/Extended Illness/Dropout Report

Date:

Player:

Team:

Date of injury or first date missed due to extended illness:

Did player dropout for the remainder of the season? Yes No

If so, last date of game or practice they participated in:

Reason player gave for dropout, if not injury or illness:

Injury or illness (E.g.: "broken arm", "mononucleosis"):

Anticipated return date:

If injury, did the injury occur during a MASCO game or practice? Yes No

If so, describe the incident and rink location:

[A copy of this form will be sent to your level director, the treasurer, and the program president.]