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Georgia Soccer
 
 

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: 
*Injured is a: 
If Other: 
*Parent/Legal Guardian's First Name: 
*Parent/Legal Guardian's Last Name: 
*Phone: 
*E-mail: 
*Confirm E-mail: