Medical Release Form - The Arc Of Buffalo County
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1Little League
®
Baseball and Softball
Medical Release
NOTE: To be carried by any Regular Season or Tournament Team
Manager together with team roster or eligibility affidavit.
Player: ___________________________________
Date of Birth: ____________
League Name: ______________________________
I.D. Number: ____________
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: ____________________________________________________________
Hospital Preference: __________________________________________________
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
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.
Date of last Tetanus Toxoid Booster: _____________________________________
Mr./Mrs./Ms. ________________________________________________________
Authorized Parent/Guardian Signature
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.
my documents/league supplies/2005/medical release form
rev. 2/05.1
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