Georgia Medical Release Form 2
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GEORGIA GYMNASTICS ACADEMY
MEDICAL RELEASE FORM
Student’s Name:__________________________DOB:_______Age:______
Home Phone:(___)____-________________Cell Phone:(___)____-____________
Address:___________________________________________________________
City:__________________________________State:_______Zip:_____________
Mother’s Name:______________________Father’s Name:__________________
Fill out the following information so we may contact you quickly in the
event of an emergency: Who to call if parents cannot be reached:
Name/Relation:_________________________________ Phone #:(___)___-_________
Child’s Doctor’s Name:___________________________ Phone #: (____)___-______
Medical Insurance Company: ______________________Policy #_________________
Any intolerance/allergy to drugs or medications?_____________________________
Please elaborate:________________________________________________________
Does the child have any medical conditions we should be aware of?_________
Please elaborate:____