Autumn Baseball League Medical Release Form
Each manager must have this completed and signed. It
must be accessible during each game.
DO NOT SUBMIT WITH TEAM REGISTRATION; HAVE AVAILABLE AT EACH GAME.
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: _____-_____-_______
Hospital Preference: ______________________________________________________
IN CASE OF EMERGENCY, CONTACT: (print)
List any allergies/medical problems, including those
requiring maintenance medication (i.e. Asthma, Seizure Disorder)
Freq. of dosage
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
Date of last Tetanus Toxoid Booster:____/____/_______
Print: parent / guardian name:__________________________________________________________
Signed: Mr./Mrs./Ms__________________________________Date signed: ___/___/______