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Little League ® Baseball and Softball

MEDICAL RELEASE

NOTE: To be carried by any Regular Season or Tournament

Team Manager together with team roster or International Tournament 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 LEGAL GUARDIAN AUTHORIZATION: Email: ____________________________

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)/legal 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.