Player: ________________________________ Date of Birth: __________ Gender (M/F):______________
Parent(s)/Legal Guardian Name:___________________________ Relationship:_______________________
Parent(s)/Legal 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 Certied
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/Legal 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.
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 Adavit.
