WLL Medical Release

Medical Release

Wethersfield Little League
Player Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Gender

Other
Division
Parent/Legal Guardian Name

First NameLast Name
Relationship
Parent/Legal Guardian Name

First NameLast Name
Relationship
Player's Address

Player’s Address

Street Address Line 2

CityState/Country

Zip
Preferred Phone
Format: (000) 000-0000.
Other Phone
Format: (000) 000-0000.
Preferred Email
example@example.com
If Parent(s)/Legal Guardian cannot be reached in case of emergency, contact

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

First NameLast Name
Phone
Format: (000) 000-0000.
Relationship to Player
MEDICAL HISTORY:
Medical Diagnoses
If none, please type N/A
Allergies:
If none, please type N/A
Medications:
If none, please type N/A
Date of last Tetanus booster (if known)

MonthDayYear
Date
PARENT OR LEGAL GUARDIAN AUTHORIZATION:
In case of emergency, and I cannot be reached, I hereby authorize my child to be treated by certified emergency personnel (i.e. first responder, EMS, emergency department staff)
Date

MonthDayYear
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 Name
League ID
Team
Date

MonthDayYear
Date
Should be Empty:

Medical Release

MEDICAL HISTORY:

PARENT OR LEGAL GUARDIAN AUTHORIZATION:

FOR LEAGUE USE ONLY: