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.
Team Details
*
Baseball or Softball
Division
Team Name
Player Name:
Date of Birth:
-
Month
-
Day
Year
Date
Gender (M/F):
Parent 1 /Legal Guardian Name:
Relationship:
Parent 2 /Legal Guardian Name:
Relationship:
Player's Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell Phone:
Format: (000) 000-0000.
Alternate Phone:
Format: (000) 000-0000.
PARENT OR LEGAL GUARDIAN AUTHORIZATION:
Email Address:
example@example.com
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:
Format: (000) 000-0000.
Address:
Street Address
Street Address Line 2
City
State / 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
Phone
Format: (000) 000-0000.
Relationship to Player
Name
Phone
Format: (000) 000-0000.
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
1
2
3
4
Date of last Tetanus Toxoid Booster:
-
Month
-
Day
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.
Mr./Mrs./Ms. Authorized Parent/Legal Guardian Signature
*
Date:
-
Month
-
Day
Year
Date
FOR LEAGUE USE ONLY:
League Name:
League ID:
Division:
Team:
Date:
-
Month
-
Day
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.
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