MEDICAL RELEASE

Note: To be carried by any regular season or tournament team manager/coach together with team roster affidavit.
Players Last Name: First Name: Middle Name:

Parent/Legal Guardian Name: Relationship:

Contact Number (Cell Phone):

Parent/Legal Guardian Name: Relationship:

Contact Number (Cell Phone):

Players Address: City: State: Zip Code:

Home Phone:

Email Address:

Parent or Legal Guardian Authorization

In case of an emergency, I hereby authorize my child to be treated by Certified Emergency Personnel.
Family Physician: Phone Number:

Address: City: State:

Insurance Company: Policy # Group ID#

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

Name: Phone # Relationship to Player:

Name: Phone # Relationship to Player:

Medical History
Medical Diagnosis Medication Dosage and Frequency

Date of last Tetanus 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 or Guardian Signature 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.

OFFICE USE ONLY:

League Name: Grayling Little League Division:_Coach Pitch 9&10 11&12 13&14

Team_________________________________ BASEBALL SOFTBALL