Little League Baseball And Softball Medical Release
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1
2Little 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: ______________ _
J.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: ___________________ _
M r./M rs ./M s.
--:--,-;---:------:---::-_-:-:-::::----:-:-_=-_,--_ _ _ _ _ _ _ _ _ _ _
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.
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