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.