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IntergalactiCON
Home
About
Corporate Partners
The Ultimate Assist
Meetings & Events
LiveBarn Game Streaming
Lattimore Physical Therapy
Iceplex Fitness
Press & Media
Press Releases
Media Coverage
Visitor Center
Play
Public Skating
Public Skating Refunds
Birthday Parties
Group Outings
Learn
Learn to Ice Skate
Learn to Play Hockey
Hockey 101
Never Ever League
I-League
Learn to Figure Skate
Zamboni Experience
Train
Skate & Shoot
Adult Skate & Shoot
Youth Skate & Shoot
Stick & Puck
NewEdge Hockey Development
Compete
The Iceplex Adult Hockey League
Youth Spring Hockey League
Youth Summer Hockey League
Facility Schedule
Tickets
Stick & Puck
Skate & Shoot
Public Ice Skating
Rage in the Cage 22
IntergalactiCON
INCIDENT REPORT FORM
Name Of Rink:
Bill Gray's Regional Iceplex
Rink Address:
2700 Brighton Henrietta TL RD, Rochester, NY 14623
*
Indicates required field
PERSON COMPLETING REPORT
*
DATE OF INCIDENT
*
DAY
*
MONDAY
TUESDAY
WEDNESDAY
THURSDAY
FRIDAY
SATURDAY
SUNDAY
TIME
*
AM/PM
*
AM
PM
NAME OF INJURED PERSON
*
First
Last
[object Object]
AGE
*
MALE/FEMALE
*
MALE
FEMALE
INJURED PERSON ADDRESS
*
CITY
*
STATE
*
ZIP
*
INJURED PERSON PHONE NUMBER
*
IF INJURED PERSON WAS A MINOR, WERE PARENTS NOTIFIED?
*
YES
NO
IF INJURED PERSON WAS A MINOR, WERE PARENT'S PRESENT
*
YES
NO
EVENT TAKING PLACE ON RINK AT TIME OF ACCIDENT
*
HOCKEY GAME
PUBLIC ICE SKATE
IAHL
NEL
H101
S101
FS101
SPECIAL EVENT
NAME OF PERSON NOTIFIED
*
RELATIONSHIP TO INJURED PERSON
*
ADDRESS OF PERSON NOTIFIED
*
CITY
*
STATE
*
ZIP
*
PHONE NUMBER
*
DESCRIPTION OF INJURY
*
HOW DID THE INCIDENT OCCUR? (DESCRIBE ENTIRELY AND FULLY BASED ON THE PATRON'S WORDS)
*
TYPE OF AID GIVEN
*
WAS INJURED PERSON TAKEN TO HOSPITAL?
*
YES
NO
IF YES, WHICH HOSPITAL
*
STRONG
HIGHLAND HOSPITAL
UNITY
ROCHESTER GENERAL HOSPITAL
MONROE COMMUNITY HOSPITAL
IF INJURED PERSON WAS NOT TAKEN TO HOSPITAL, WHAT ACTION WAS TAKEN?
*
COMPLETE BELOW IF DURING PUBLIC SKATE
NAMES OF SKATE GUARDS ON SITE:
*
APPROXIMATE ATTENDANCE
*
Submit