Medical Release

NOTE: To be carried by any Regular Season or Tournament Team Manager

Player: *

Date of Birth: *

Gender (Male/Female): *

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 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: *

Address: *

City: *

State/Country: *

Zip: *

Hospital Preference: *

Parent Insurance Co: *

Policy No.: *

Group ID No.: *

League Insurance Co: *

Policy No.: *

League/Group ID No.: *

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

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: *

Medical Diagnosis: *

Medication: *

Dosage: *

Frequency of Dosage: *

Medical Diagnosis: *

Medication: *

Dosage: *

Frequency of Dosage: *

Date of last Tetanus Toxoid Booster: *

The purpose of the above lister information is to ensure that medical personnel have details of any medical problem which may interfere with or alter treatment.

Authorized Parent/Guardian Signature (Mr./Mrs./Ms./): *

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.

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Medical Release

​Medical Release

Medical Release