BEAUMONT BASEBALL

LITTLE LEAGUE BASEBALL MEDICAL RELEASE FORM

NOTE: To be carried by any Regular Season or Tournament
Team Manager together with team roster or International Tournament affidavit.

* Player Name:

* Birth Date:

* Gender:

* Parent/Guardian Name:

* Relationship to Player:

* Phone Number:

* Parent/Guardian Name:

* Relationship to Player:

* Phone Number:

* Player's Address:

* City:

* State:

* Zip Code:

PARENT OR 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:

* Phone Number:

* Address:

* City:

* State:

* Zip Code:

* Hospital Preference:

* Parent Insurance Co:

* Policy Number:

* Group ID:

If parent(s)/guardian cannot be reached in case of emergency, contact:

* Name:

* Phone Number:

* 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)

* Please List Medical Diagnosis, Medication, Dosage and 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.

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.

I/We Agree With the Above *

* indicates required fields

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LITTLE LEAGUE BASEBALL MEDICAL RELEASE FORM