Little League Baseball
M E D I C A L  R E L E A S E 
 
NOTE:  To be carried for the 2020 Spring Season by the 
Team Manager together with team roster.  
 
*indicates required information 
 +
Gender (M/F): *
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)
If parent(s)/legal guardian cannot be reached in case of emergency, contact:  
 
 
Please list one emergency contact other than a parent. 
Please list any allergies/medical problems, including those requireing maintenance medication. (i.e. Diabetic, Asthma, Siezure Disorder)
 Medical DiagnosisMedicationDosageFrequency of Dosage
1
2
3
4
COVID-19 History of Exposure
Within the last 14 days, have you had contact with any person who has been tested positive for an infection with the COVID-19? *
Have you ever been admitted to or visited a hospital in the past month? *
Have you experienced any of the following symptoms during the past 14 days? *
 YesNo
Fever (>100.4 F)
Cough
Dyspnea
Sore Throat
Chest Pain
Conjunctivitis
Myalgia
Chills
Vomiting/Nausea
Diarrhea
Skin hemorrhage
Rash
Fatigue/Tiredness
Headache
Loss of taste
Loss of smell
PLEASE BE AWARE THAT IF YOU HAVE ANSWERED YES TO ANY OF THE ABOVE QUESTIONS, YOU SHOULD STAY AT HOME, INFORM YOUR TEAM MANAGER AND FOLLOW LOCAL PUBLIC HEALTH GUIDELINES. 
 +
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. 
 +
Authorized Parent/Guardian Signature *
clear