Rancho Buena Vista Little League

Medical Release

Little League Baseball and Softball

MEDICAL RELEASE

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

* Player:

* Date of Birth:

* Gender:

* Parent/Guardian Name:

* Relationship:

Parent/Guardian Name:

Relationship:

* Player's Address:

* City:

* State/Country:

* Zip Code:

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:

* Hospital Preference:

* Parent Insurance Company:

* Policy Number:

* Group ID:

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

* Name:

* Phone:

* 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)

Medical Diagnosis:

Medication:

Dosage:

Frequency of Dosage:

Please list any other diagnoses and/or medications:

* Date of last Tetanus Toxiod 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.

* Authorized Parent/Guardian Signature (Type Full Name):

* Date:

* indicates required fields

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Medical Release