Little League Medical Release

Player:*

First NameLast Name
Date of Birth:*

MonthDayYear
Date
Gender:*
Parent(s)/Legal Guardian Name:*

First NameLast Name
Relationship:*
Parent(s)/Legal Guardian Name:

First NameLast Name
Relationship:
Player Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mobile Number:*
Please enter a valid phone number.Format: (000) 000-0000.
Home Number:
Please enter a valid phone number.Format: (000) 000-0000.
Work Number:
Please enter a valid phone number.Format: (000) 000-0000.
Email:
example@example.com
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:*
Please enter a valid phone number.Format: (000) 000-0000.
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Hospital Preference:*
Parent Insurance Co.:
Policy No.:
Group ID#:
League Insurance Co.:
Policy No.:
League/Group ID#:
If Parent(s)/Legal Guardian cannot be reached in case of emergency, contact:
Name:*

First NameLast Name
Phone Number:*
Please enter a valid phone number.Format: (000) 000-0000.
Relationship:
Name:

First NameLast Name
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Relationship:
Please list any allergies/medical problems, including those requiring maintenance medication (i.e. Diabetic, Asthma, Seizure Disorder).

Date of last Tetanus Toxoid Booster:
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
Date:

MonthDayYear
Date
Should be Empty:

PARENT OR LEGAL GUARDIAN AUTHORIZATION: