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Guelph Minor Hockey Association Concussion Reporting - House League
This form shall be completed by the Team Trainer, or Coach in the absence of Team Trainer, when a GMHA player or on ice coach/trainer/volunteer incurs any trauma to the head. Please provide your email address.
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Email *
Who is Reporting the Concussion *
First and Last Name of Person Filing Report *
Injured Player/Member's Name *
Age Group and Team Name *
Where did the concussion take place?
 *
Date/Time of Injury *
Arena Location (if applicable)
Indicate all of the symptoms observed/reported at the time of trauma
 *
Required
Did the Player/Member sustain any other injuries? *
What treatment was employed at the time of the trauma? Please describe.
 *
Has the player/member been seen by a medical professional? 
 *
Has the player/member completed baseline concussion testing this season?
 *
Has a treatment plan been established?
 *
A copy of your responses will be emailed to the address you provided.
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