Little League Baseball®
Medical Release (Note: To be carried by any Regular Season or Tournament Team Manager together with team roster or eligibility affidavit at all practices/games.)

Player's Name: ___________________________________________ Date of Birth: _____________________
League Name: ___________________________________________ League ID No.: __ __ __ - __ __ -__ __ __

Parent or Guardian Authorization:
In case of an emergency, if I, or the family physician, cannot be reached, I hereby authorize my child to be treated by Certified Emergency Personnel (i.e. EMT, First Responder, ER Physician).
Family Physician:_________________________________________ Phone: (_____) __________________
Address:_________________________________________________ City: ___________________________
Hospital Preference: ________________________________________________________________________
In case of emergency, contact:
__________________________________________________________________________________________
Name                                                     Phone (Work)                           Relationship to Player
__________________________________________________________________________________________
Phone (Home)                                          Phone (Cell)                             Pager Number
__________________________________________________________________________________________
Name                                                     Phone (Work)                           Relationship to Player
__________________________________________________________________________________________
Phone (Home)                                          Phone (Cell)                             Pager Number
Please list any allergies/medical problems, including those requiring maintenance medication:
(i.e. diabetic, asthma, seizure disorder) Medical Diagnosis Medication Dosage Frequency of Dosage
__________________________________________________________________________________________
__________________________________________________________________________________________
Allergies: _________________________________________________________________________________
(The purpose of the above listed information is to ensure that medical personnel have details of any medical
concern which may interfere with or alter treatment.)
Date of last Tetanus Booster: ______________________

Mr./Mrs.___________________________________________________________ Date:__________________

Authorized Parent/Guardian Signature

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 or religious preference.