ASG Georgia Medical Release Form
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ASG GEORGIA MEDICAL RELEASE FORM

I, _______________________ (parent/guardian’s name) hereby give permission for any
and all medical attention to be administered to my child_______________________
(child’s name) in the event of accident, injury, sickness, etc., under the direction of the
person(s) listed below, until such time as I may be contacted. I also assume the responsibility
for the payment of any such treatment. This release is effective for the period of one year
from the date given below.
Address:
Home Phone:
Insurance Co:
Policy Number:

________________________________________________
________________________________________________
________________________________________________
________________________________________________

In case I cannot be reached, any of the following person/s is/are designated to act on my
behalf:
Coach:
Assistant Coach:
Team Manager:
Parent:

________________________________________________
________________________________________________
_____