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Little League Baseball Medical Release

PLAYER INFORMATION

* First Name:

* Last Name:

LEAGUE NAME: HAMPTON WYTHE LITTLE LEAGUE:

* Birthdate:

* Age:

PARENT/GUARDIAN AUTHORIZATION:

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:

* Address:

* Work Phone:

* Hospital Preference::

MEDICAL/EMERGENCY CONTACT INFORMATION

* Emergency Contact Name:

* Phone Number:

* Relationship to Player:

Emergency Contact Name:

Phone Number:

Relationship to Player:

Please list any allergies/medical problems, including those requiring maintenance medication. (i.e. Diabetic, Astham, Seizure Disorder)

Medical Comments - Allergies, Medications, Special Conditions, Etc?:

Medical Diagnosis:

Medication:

Dosage:

Frequency of Dosage:

Medical Diagnosis:

Medication:

Dosage:

Frequency of Dosage:

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.

* Date of last Tetanus Toxoid Booster::

I/we agree with the above *

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, sexual preference or religious preference.

WARNING:

Signature:

Date:

* indicates required fields

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Little League Baseball Medical Release