Incident Reports - Tim Hortons Iceplex

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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 *

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 *

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

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2700 Brighton Henrietta Townline Rd
Rochester, NY 14623
(585) 424-4625

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© 2013-2024 | Tim Hortons Iceplex | All Rights Reserved | Privacy Policy | Legal Notice

© 2013-2023 | Tim Hortons Iceplex | All Rights Reserved | Privacy Policy | Legal Notice

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Bill Gray's Regional Iceplex
2700 BRIGHTON HENRIETTA TOWNLINE RD
Rochester, ny 14623

[585] 424-4625

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