2022 LL BB & SB MEDICAL RELEASE

Little League ® Baseball and Softball

MEDICAL RELEASE
Player*
Date of Birth*

MonthDay Year
Date
Gender (M/F)*
Player Address*

Street Address

City State

Zip Code
Player Division
Parent(s)/Guardian Name 1*
Relationship*
Home Phone
Work Phone
Mobile Phone*
Email*
example@example.com
Parent(s)/Guardian Name 2
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*
Address*

Address

Street Address Line 2

City State/Country

Postal / Zip Code
Hospital Preference*
Parent Insurance Co*
Policy No.*
Group ID#*
If parent(s)/legal guardian cannot be reached in case of emergency, contact:
Name*
Phone*
Relationship to Player*
Name*
Phone*
Relationship to Player*

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

Date of last Tetanus Toxoid Booster*

MonthDay Year
Date
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.
Mr./Mrs./Ms.*

Authorized Parent/Guardian Signature Clear
Date*

MonthDay Year
Date
League Insurance Company
Policy Number
League/Group ID
Team
Date Assigned

MonthDay Year
Date
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:

Little League ® Baseball and Softball