Ambulance Police Incident Report

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					                             Ambulance / Police Incident Report
                     (Please Type directly on this form- Select Insert Button to overtype lines)

If at any time the Police or Ambulance is called to the ice Rink during your Hockey game, the following report must be
                                     filled out and sent to your Area Supervisor.



     Date of Incident: _______________________ Time of Incident: _____________ Level: _____________
                                                      (Approximate time during game & period)

     Location: ____________________________________________________ (Name of Ice Rink/Pad #)

     Home Team: ________________________________ Visiting Team: _____________________________

     Report Details (Be as specific as possible, Name, Numbers, etc)

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     (If you need more room to describe incident use the page below)

     Referee’s Name: ____________________________ Telephone Number: (                           )______________________

     Referee’s Partner(s) Name: ______________________________________________________________



     Signature: ______________________________________ Date: _________________________
     Print out 2 copies, sign one and send hard copy to Supervisor
                    Ambulance / Police Incident Report
                                           Page 2



Date of Incident: _______________________ Time of Incident: _____________ Level: _____________
                                        (Approximate time during game & period)




Report Details (Be as specific as possible, Name, Numbers, etc) Continued
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