Medical Release Form

Please fill out the following Medical Release Form for any players participating in Yarmouth Little League. Required fields are noted with a star (*). Please include a signature at the bottom by signing with your cursor (desktop) or finger (mobile).

    Player Information

    Player Name*

    Date of Birth*

    Gender
    MaleFemale

    Player Street Address*

    Player City*

    Player State/Country*

    Player Zip Code*

    Parent(s) / Guardian #1

    Name*

    Relationship*

    Parent(s) / Guardian #2

    Name

    Relationship

    Contact Information

    Home Phone*

    Work Phone

    Mobile Phone

    Email*

    Parent or Legal 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)

    Yes, I authorize this

    Medical Information

    Family Physician

    Phone

    Address

    City

    State/Country

    Hospital Preference

    Insurance Information

    Parent Insurance Co.

    Parent Policy No.

    Parent Group ID#

    League Insurance Co.

    League Policy No.

    League Group ID#

    Emergency Contacts

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

    Emergency Contact #1

    Name*

    Phone*

    Relationship to Player*

    Emergency Contact #2

    Name

    Phone

    Relationship to Player

    Medications

    Please list any allergies / medical problems, including those requiring maintenance medication. (i.e. Diabetic, Asthma, Seizure Disorder)

    Medical Diagnosis

    Medication

    Dosage

    Frequency of Dosage

    Date of Last Tetanus Toxoid 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.

    Signature*

    Please sign below:

    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.