Fillable Medical Release Form printable pdf download

HIGHLAND L ITTLE L EAGUE

MEDICAL R ELEASE F ORM

Player N ame: _ _________________________________________ B irthdate: _ ____________________ G ender :

Player’s A ddress: _ ____________________________________________________________________________________________

City: _ __________________________________________ S tate: _ _______________ Z ip: _ ________________________________

: _ __________________________________________________________

: _ ________________

Parent(s)/Guardian N ame

R elationship

Home P hone: _ _______________________ C ell P hone: _ ________________________ W ork P hone: _ ________________________

email: _ _____________________________________________________________________________________________________

: _ __________________________________________________________

: _ ________________

Parent(s)/Guardian N ame

R elationship

Home P hone: _ _______________________ C ell P hone: _ ________________________ W ork P hone: _ ________________________

email: _ _____________________________________________________________________________________________________

PARENT O R G UARDIAN A UTHORIZATION:

In c ase o f e mergency, I h ereby a uthorize t he L eague t o t ake t he i njured p layer t o t he h ospital f or t reatment o f a n i njury s ustained

during a ny g ame o r s cheduled p ractice h eld i n t he T own o f H ighland. I n t he e vent o f a n i njury o utside o f t he T own o f H ighland, I

authorize t he L eague t o t ake t he i njured p layer t o t he n earest h ospital o r c linic f or t reatment.

Family P hysician: ____________________________________________

Phone: _ ___________________________________

Address / C linic: _ ____________________________________________

City: _ ______________________ State: _ _______

Hospital P reference: _ _________________________________________________________________________________________

If p arent(s)/guardian c annot b e r eached i n c ase o f e mergency, c ontact:

Name: _ __________________________________ Phone: _ ____________________ R elationship t o p layer: _ _______________

Please l ist a ny m edical i nformation t he l eague s hould k now a bout ( Allergies, P hysical L imitations, E tc.)

____________________________________________________________________________________________________________

Parent / G uardian S ignature: _ __________________________________________________________________________________

WHITE – P layer A gent Y ELLOW -‐ T reasurer

Medical Release Form

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