This form is to be used after an athlete has been removed from athletic activity due to a suspected concussion to report data to the MWAHA Player Safety Coordinator for use in the USA Hockey Player Safety Initiative.

LIHA's Referee-in-Chief assumes all responsibilities for, and oversight of, the officials and officiating program of the LIHA.

LIHA and USA Hockey discourage players from playing up. Should your player choose to try-out for a team that is out of their age group, you must complete, sign, and return this form to the LIHA Coaching Director for review.