MLL - Medical Release Form
NOTE: Little League International requires this form to be carried by your Regular Season Team Manager together with a Team Roster during practices and games.

Information is kept confidential and will not be disclosed.

IMPORTANT NOTE:
If you have more than one child in the league...
    ...fill out ONE FORM FOR EACH CHILD.

If you have any errors or unable to fill out the form - stop and email us at mediall@dca.net.


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Full Name of Player (as you entered in Registration Portal) *
Date of Birth *
MM
/
DD
/
YYYY
Gender *
Player's Address (Street, City, State, and Zip) *
PARENT OR LEGAL GUARDIAN INFORMATION
P/G 1 - Parent(s)/Guardian Name (1) *
P/G 1 - Relationship to Player *
P/G 1 - Parent Email(s) *
P/G 1 - Cell Phone Number (xxx-xxx-xxxx) *
P/G 2 - Parent(s)/Guardian Name (2)
P/G 2 - Relationship to Player
P/G 2 - Parent Email(s)
P/G 2 - Cell Phone Number (xxx-xxx-xxxx)
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)

Player's Physician *
Physician's Phone Number *
Physician's Address (Street, City, and State)
Hospital Preference *
Insurance Company Covering Player (25 characters) *
Insurance Policy # / Group # (on Insurance Card) *
EMERGENCY CONTACTS
If parents / legal guardian cannot be reached in case of emergency, contact one of the following.

DO NOT enter the parents NOR guardians listed above.

Emergency Contact 1 - Name *
Emergency Contact 1 - Phone Number (xxx-xxx-xxxx) *
Emergency Contact 1 - Relationship to Player *
Emergency Contact 2 - Name *
Emergency Contact 2 - Phone Number (xxx-xxx-xxxx) *
Emergency Contact 2 - Relationship to Player *
ALLERGIES AND MEDICAL ISSUES
Please list any allergies/medical problems, including those requiring maintenance medication. (i.e. Diabetic, Asthma, Seizure Disorder)

Limited to 4 lines, each being 85 characters.  If you have more information we should know, please email us at mediall@dca.net.

The purpose of this information is to ensure that medical personnel have the details of any medical problem which may interfere with or alter treatment.

Medication for Medical Diagnosis 1 (Name of Condition, Name of Medicine, Dosage, and Frequency)
Medication for Medical Diagnosis 2 (Name of Condition, Name of Medicine, Dosage, and Frequency)
Medication for Medical Diagnosis 3 (Name of Condition, Name of Medicine, Dosage, and Frequency)
Medication for Medical Diagnosis 4 (Name of Condition, Name of Medicine, Dosage, and Frequency)
Date of last Tetanus Toxoid Booster *
MM
/
DD
/
YYYY
e-SIGNATURE OF AUTHORIZED PARENT OR GUARDIAN
In the final question, below, please enter the Full Legal Name of the Authorized Parent or Guardian filling out this form.

e-Signatures are completely legal, and they have the same legal weight as handwritten signatures. According to the Electronic Signatures in Global and National Commerce Act, otherwise known as the "ESIGN Act,” electronic signatures have the same legal standing as signatures using pen and paper.

One of the most commonly used electronic signatures today is the Text Typed signature; meaning that one has used a keyboard to type their name, with the intent to sign “something”. Although Text Typed is the most common, electronic signatures are not limited to this method.

Full Name for Authorized Parent/Guardian Electronic Signature *
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