POWLL MEDICAL RELEASE

Little League ® Baseball and Softball
MEDICAL RELEASE
Player
Date of Birth

MonthDayYear
Date
Gender M/F
Parent/Guardian 1
Name
Parent/Guardian 1
Relationship
Parent/Guardian 2
Name
Parent/Guardian 2
Relationship
Player's Address

Street Address

Street Address Line 2

CityState/Country

Zip
Home Phone
Format: (000) 000-0000.
Work Phone
Format: (000) 000-0000.
Mobile Phone
Format: (000) 000-0000.
Email
example@example.com
PARENT OR LEGAL GUARDIAN AUTHORIZATION:
Family Physician
Phone
Format: (000) 000-0000.
Address

Address

Street Address Line 2

CityState/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
Contact 1
Name
Contact 1
Please enter a valid phone number.Format: (000) 000-0000.
Contact 1
Relationship to Player
Contact 2
Name
Contact 2
Please enter a valid phone numberFormat: (000) 000-0000.
Contact 2
Relationship to Player

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

Rows	Medical Diagnosis	Medication	Dosage	Frequency of Dosage

Date of last Tetanus Toxoid Booster

MonthDayYear
Date
Do you have an additional form to complete for another child?
Authorized Parent/Guardian Signature
Mr./Mrs./Ms.
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: