Little League Baseball And Softball Medical Release
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1Little League
Baseball and Softball
®
M E D I C A L
R E L E A S E
NOTE: To be carried by any Regular Season or Tournament
Team Manager together with team roster or eligibility affidavit.
Player: _____________________________________
Date of Birth: ____________ Gender (M/F):_________________
Parent (s)/Guardian Name:_____________________________________ Relationship:____________________________
Parent (s)/Guardian Name:_____________________________________ Relationship:____________________________
Player’s Address:____________________________________ City:_______________ State/Country:________ Zip:______
Home Phone:_____________________ Work Phone:______________________ Mobile Phone:_____________________
PARENT OR 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)/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
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/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.
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Parent category: Legal