MEDICAL WAIVER | BULLDOGS

Medical Release

Player Name (as registered)

Parent/Legal Guardian

Player Date of Birth

Relationship

Player Address

City

State

Zip Code

Home Phone

Work Phone

Cell

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, ER Physician)

Family Physician

Phone

Address

City

State

Hospital Preference

Parent Insurance Co.

Policy #

Group ID#

If Parent/legal guardian cannot be reached in case of emergency, contact:

Name

Phone

Name

Phone

Relationship to Player

Please list any allergies/medical problems, including those requiring maintenance medication (asthma, diabetes, seizure disorder, etc.)

Medical Diagnosis

Medication

Medical Diagnosis

Medication

Dosage

Frequency of Dosage

Dosage

Frequency of Dosage

Date of Last Tetanus Toxoid Booster

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

Auhorized Parent/Guardian Signature

Date

Thanks for submitting!

OFFICIAL HOME OF THE BURR RIDGE

WILLOWBROOK LITTLE LEAGUE

Medical Release

If Parent/legal guardian cannot be reached in case of emergency, contact:

Please list any allergies/medical problems, including those requiring maintenance medication (asthma, diabetes, seizure disorder, etc.)

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

WARNING: Protective equipment can prevent all injuries a player might receive while participating baseball/sofball.