Autumn Baseball League

Medical Release Form

Each manager must have this completed and signed.  It must be accessible during each game.

Player________________________________________________D.O.B.___/___/______

Team name & manager:  ___________________________________________________

Parent or Guardian authorization:

In case of emergency, if family physician cannot be reached, I hereby authorized my child to be treated by Certified Emergency Personnel (EMT, First Responder, Emergency Room Physician).

Family Physician:  _______________________________Phone:  _____-_____-_______

Address:  _______________________________________________________________

Hospital Preference:  ______________________________________________________

IN CASE OF EMERGENCY, CONTACT:  (print)

Name_____________________________Phone__________________Relation________

Name_____________________________Phone__________________Relation________

Name_____________________________Phone__________________Relation________

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

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.

                                                                                 Date of last Tetanus Toxoid Booster:____/____/_______

Print:   parent / guardian name:__________________________________________________________

Signed: Mr./Mrs./Ms__________________________________Date signed: ___/___/______