Sports Medicine Expense Form – Non-Student-Athlete | UGA Athletic Association Compliance Department

Name of Individual(s) Receiving Expenses*

Sport This Request Relates To:*

Category of Individual(s):

Family Member(s) of (which student-athlete):*

If Other, please provide additional details.*

Dates treatment and expenses will be provided:

Location of Medical Treatment:

Reason For Medical Treatment:

What expenses do you wan to provide to the individaul named above?*

Submitter's Name*

First Last

Submitter's Email*

Sports Medicine Expense Form – Non-Student-Athlete