Little League Baseball Medical Release printable pdf download

Little League Baseball

Medical Release

(Note: To be carried by any Regular Season or Tournament Team Manager

together with team roster or eligibility affidavit at all practices/games.)

Player's Name:____________________________________________________ Date of Birth:________________

League Name: Anderson Township Little League

League ID No.: 00006207

Parent or Guardian Authorization:

In case of an emergency, if I, or the family physician, cannot be reached, I hereby authorize my child to be treated by

Certified Emergency Personnel (1.e. EMT, First Responder, ER Physician).

Family Physician:__________________________________________ Phone: (____)_____________

Address:__________________________________________________ City:________________________________

Hospital Preference: ____________________________________________________________________________

In case of emergency, contact:

_____________________________________________________________________________________________

Name

Phone (Work)

Relationship to Player

______________________________________________________________________________________________

Phone (Home)

Phone (Cell)

Pager Number

______________________________________________________________________________________________

Name

Phone (Work)

Relationship to Player

______________________________________________________________________________________________

Phone (Home)

Phone (Cell)

Pager Number

Please list any allergies/medical problems, including those requiring maintenance medication:

(i.e. diabetic, asthma, seizure disorder)

Medical Diagnosis

Medication

Dosage

Frequency of Dosage

______________________________________________________________________________________________

Allergies:______________________________________________________________________________________

(The purpose of the above listed information is to ensure that medical personnel have details of any medical concern

which may interfere with or alter treatment.)

Date of last Tetanus Toxoid Booster: _____________________

Mr./Mrs._________________________________________________________ Date:__________________

Authorized Parent/Guardian Signature

WARNING: Protective equipment cannot prevent all injuries a player might receive while participating in Baseball/Softball.

Little League Baseball does not limit participation in its activities on the basis of disability, race, color, creed,

national origin, gender or religious preference.

Little League Baseball Medical Release

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