POWLL MEDICAL RELEASE

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

Date of last Tetanus Toxoid Booster

MonthDayYear
Date
Do you have an additional form to complete for another child?

YesNo
Authorized Parent/Guardian Signature
Mr./Mrs./Ms.

Clear
Signature Date
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.
Calculation
Should be Empty:

MEDICAL RELEASE