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Georgia State Soccer Association, Inc. Injury Report

Attention: This form should be completed by a Team Official and not by a Parent.

Section 1 - Injured Person's Information

*First Name:
Middle Name:
*Last Name:
*Address:
*City:
*State:
*Zip:
*Birth Date:
*Gender:	Female Male
*Injured is a:	Player Coach Official Other
If Other:
*Parent/Legal Guardian's First Name:
*Parent/Legal Guardian's Last Name:
*Phone:
*E-mail:
*Confirm E-mail: