2023 SPRING LITTLE LEAGUE ® BASEBALL AND SOFTBALL MEDICAL RELEASE

2023 - LITTLE LEAGUE ® BASEBALL AND SOFTBALL MEDICAL RELEASE
NOTE: To be carried by any Regular Season or Tournament Team Manager together with team roster or International Tournament Affidavit.
Player*
Date of Birth*

MonthDay Year
Date
Gender (M/F)*
Parent(s)/Legal Guardian Name:*
Relationship*
Home Phone*
Work Phone
Mobile Phone
Email*
example@example.com
Parent(s)/Legal Guardian Name:
Relationship
Player Street Address
City
State (2 letter abbreviation)
Zip Code
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*
City*
State/Country*
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.
Authorized Parent/Legal Guardian Signature *

Clear
Date*

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.
FOR LEAGUE USE ONLY:
League Insurance Co
Policy No.
League/Group ID#
League Name
League ID
Should be Empty:

2023 - LITTLE LEAGUE ® BASEBALL AND SOFTBALL MEDICAL RELEASE