2025 Medical Release

2025 Medical Release
Player Information
Player's Name*
Player's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Player's Date of Birth*

MonthDayYear
Date
Gender (M/F)*
First Parent/Guardian Name*
First Parent/Guardian Relationship*
Home Phone Number
Work Phone Number
Cell Phone Number*
Email*
example@example.com
Second Parent/Guardian Name
Second Parent/Guardian Relationship
PARENT OR LEGAL GUARDIAN AUTHORIZATION:

In case of emergency, if family physician cannot be reached, I hereby authorize my child to be treated by Certified Emergency Personnel. (i.e. EMT, First Responder, E.R. Physician)
Family Physician*
Phone Number*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Hospital Preference*
Parent Insurance Information
Parent Insurance Co
Policy No.
Group ID#
League Insurance Co.
League/Group ID#
Emergency Contacts
Emergency Contact 1 Name
Emergency Contact 1 Phone Number
Emergency Contact 1 Relationship to Player
Emergency Contact 2 Name
Emergency Contact 2 Phone Number
Emergency Contact 2 Relationship to Player
Medications

Please list any allergies/medical problems, including those requiring maintenance medication. (i.e. Diabetic, Asthma, Seizure Disorder)

Approximate Date of last Tetanus Toxoid Booster

MonthDayYear
Date
Authorized Signature
The purpose of the above listed information is to ensure that medical personnel have details of any medical problem which may interfere with or alter treatment. Please sign in the box on the right.

Clear
Date*

MonthDayYear
Date
League Name
League ID
WARNING: PROTECTIVE EQUIPMENT CANNOT PREVENT ALL INJURIES A PLAYER MIGHT RECEIVE WHILE PARTICIPATING IN BASEBALL/SOFTBALL.

Little League does not limit participation in its activities on the basis of disability, race, color, creed, national origin, gender, sexual preference or religious preference.
Should be Empty:

Player Information