Lile League
®
Baseball and Soball
MEDICAL RELEASE
NOTE: To be carried by any Regular Season or Tournament
Team Manager together with team roster or Internaonal Tournament adavit.
Player: _____________________________________ Date of Birth: ____________ Gender (M/F):_________________
Parent (s)/Guardian Name:_____________________________________ Relaonship:____________________________
Parent (s)/Guardian Name:_____________________________________ Relaonship:____________________________
Player’s Address:____________________________________ City:_______________ State/Country:________ Zip:______
Home Phone:_____________________ Work Phone:______________________ Mobile Phone:_____________________
PARENT OR LEGAL GUARDIAN AUTHORIZATION: Email: ____________________________
In case of emergency, if family physician cannot be reached, I hereby authorize my child to be treated by Cered
Emergency Personnel. (i.e. EMT, First Responder, E.R. Physician)
Family Physician: ____________________________________________ Phone: _________________________________
Address: __________________________________________ City:________________ State/Country:_________________
Hospital Preference: __________________________________________________________________________________
Parent Insurance Co:_________________________ Policy No.:__________________Group ID#:_____________________
League Insurance Co:_________________________ Policy No.:__________________League/Group ID#:______________
If parent(s)/legal guardian cannot be reached in case of emergency, contact:
___________________________________________________________________________________________________
Name Phone Relaonship to Player
___________________________________________________________________________________________________
Name Phone Relaonship to Player
Please list any allergies/medical problems, including those requiring maintenance medicaon. (i.e. Diabec, Asthma, Seizure Disorder)
Medical Diagnosis Medicaon Dosage Frequency of Dosage
Date of last Tetanus Toxoid Booster: ______________________________________________________________________
The purpose of the above listed informaon is to ensure that medical personnel have details of any medical problem which may interfere with or alter treatment.
Mr./Mrs./Ms. ________________________________________________________________________________________
Authorized Parent/Guardian Signature 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.
Lile League does not limit parcipaon in its acvies on the basis of disability, race, color, creed, naonal origin, gender, sexual preference or religious preference.
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