Roller Derby Canada Injury Report Form

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If you have had an injury that has interrupted your skating and ability to attend practice, please fill out the form below. Once the form is filled out we will email you a claim form to fill out. Make sure you have seen a doctor within 30 days of your injury and have the doctor fill out the physicians portion of the claim form.

First Name *

Legal Name

Last Name *

Legal Name

League Name *

Choose your injury requirement *

I require paperwork to submit a claim.

I am notifying you of an accident but it has had minor impact and I DO NOT require a claim form.

Other:

Required

When did your injury occur? *

YYYY

Where did your injury occur? *

City, Province, Or location if in the USA

Describe your accident *

How did your accident happen?

What is the resulting injury?

Did you injury require hospitalization? *

Yes

What other coverage does the injured party have other than provincial health care? *

Email Address *

Please provide a contact phone number *

Submit

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