Medical Release Form

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.

"*" indicates required fields

Player*

Date of Birth*

Gender*

Parent(s)/Legal Guardian Name*

Relationship*

Parent(s)/Legal Guardian Name*

Relationship*

Player’s Address*

City*

State/Country*

Zip*

Home Phone*

Work Phone*

Mobile Phone*

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

Address

City

State/Country

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

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).

Medical Diagnosis

Medication

Dosage

Frequency of Dosage

Medical Diagnosis Value 1

Medication Value 1

Dosage Value 1

Frequency of Dosage Value 1

Medical Diagnosis Value 2

Medication Value 2

Dosage Value 2

Frequency of Dosage Value 2

Medical Diagnosis Value 3

Medication Value 3

Dosage Value 3

Frequency of Dosage Value 3

Medical Diagnosis Value 4

Medication Value 4

Dosage Value 4

Frequency of Dosage Value 4

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.

Mr./Mrs./Ms.

Authorized Parent/Legal Guardian Signature

Date

FOR LEAGUE USE ONLY:

League Name

League ID

Division

Team

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.

Medical Release Form

LITTLE LEAGUE ® BASEBALL AND SOFTBALL

MEDICAL RELEASE

PARENT OR LEGAL GUARDIAN AUTHORIZATION

If Parent(s)/Legal Guardian cannot be reached in case of emergency, contact

FOR LEAGUE USE ONLY:

PARKLAND LITTLE LEAGUE

information@parklandll.com