NEWPORT COUNTY CHALLENGER ® Baseball and Softball (NEWPORT BABE RUTH BAMBINO)

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MEDICAL RELEASE FORM

Email *

PLAYERS NAME AND DATE OF BIRTH *

Parent (s)/Guardian Name: *

PARENT(S) OR GUARDIAN ADDRESS CITY, STATE, ZIP *

PLAYERS ADDRESS CITY,STATE,ZIP IF DIFFERENT

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

PLAYER'S PHYSICIAN'S NAME, ADDRESS, AND PHONE NUMBER *

Hospital Preference: *

Parent or Player's Insurance Co:_________________________ Policy No.:__________________Group ID#:_____________________ *

If parent(s)/legal guardian cannot be reached in case of emergency, contact: NAME & PHONE NUMBER. Please list 2 *

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

Date of last Tetanus Toxoid Booster: *

YYYY

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.Mr./Mrs./Ms. ___________________________________________________Authorized Parent/Guardian Signature Date: *

FOR LEAGUE USE ONLY:League Name:_______________________________________________ League ID:________________________________Division:_________________________________Team:______________________________ 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.

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