Special Note: This form must be dated after January 1, 2014 and then submitted to BTYFL. No other forms are acceptable unless Section II
is modified or substituted ONLY to comply with local and/or state laws or because of medical practitioner regulations (i.e. the medical practice
insists on its own form). In either case, Section I must still be filled out entirely and attached to the modified/substituted form. Section II must be
completed in its entirety ONLY by a Licensed State Examiner (medical doctor, nurse practitioner, etc.)

Section I: FOR PARENT/GUARDIAN COMPLETION ONLY

Legal Name of Participant (must match birth certificate):

Last ________________________________________________ First ____________________________________ Middle _______________

Address: _____________________________________________ City ________________________________________ State _____ Zip ______

Telephone No ___________________________________ Date of Birth _______________________________ Male _________ Female ______
Name of Primary Medical Insurance Company ______________________________________________ Policy Number _________________

Membership Number ____________________________________________ Name of Primary Insured _________________________________

School Attended ______________________________________________ e-mail address ____________________________________________

PARTICIPANT MEDICAL HISTORY

1. Are there any injuries requiring medical attention? Yes No

2. Are there any past surgeries or scheduled surgeries? Yes No

3. Is the participant currently under the care of a medical practitioner? Yes No

4. Is the participant currently taking any medication? Yes No

5. Does the participant have any allergies (penicillin, bee stings, etc)? Yes No

6. Does the participant have asthma/require the use of an inhaler? Yes No

7. Is the participant diabetic/require medication for diabetes? Yes No

8. Does the participant currently require medication? Yes No

9. Does/has the participant have/had seizures? Yes No

10. Does the participant wear glasses or contact lenses? Yes No

11. Does the participant wear a brace or other medical support device? Yes No

12. Does the participant have any other physical limitations or medical conditions? Yes No

If you answered yes to any of the above questions, please provide the question number and an explanation in the following space:

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I hereby certify that this information is accurate to the best of my knowledge. I understand that this medical authorization may be voided in the event
of injury, illness or accident and my child may not be cleared for participation at such time. Furthermore, I hereby acknowledge that it is my
responsibility to inform my child’s coach or organization official in writing if there is any change in the medical condition of my child. I also understand
that it’s my responsibility to obtain written permission from my child’s physician on official medical stationary in order to seek permission for my child
to resume participation after any and all such injury, illness or accident.

Signature of Parent or Legal Guardian ______________________________________________________________________________________

Print Name ___________________________________________________________________________________________________________

Relationship to Participant _____________________________________________________________________________________________

Date _______________________________