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Masco Youth Hockey
Injury/Extended Illness/Dropout Report
Date of injury or first date missed due to extended illness:
Did player dropout for the remainder of the season?
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?
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.]