Wild Rose Paramedic Report

To be completed by the medical personnel that attended the Wild Rose Competition.

Competition Name

Competition Start Date

Competition End Date

Competition Location

Competition Manager Name

Competition Manager Email

Competition Manager Phone

Total number of incidents attended to:

Number of incidents considered major/serious by paramedic:

Number of incidents in which a concussion was suspected by paramedic:

Number of incidents where paramedic recommended the athlete withdraw from competition due to severity/nature of injury:

Name of Attending

Medical Personnel/Report Submitted by:

First name

Last name

Signature

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Date Report Submitted

Medical Personnel Email

Medical Personnel Phone