Little League Medical Release

Complete this form, sign with your finger or mouse, then choose Download signed PDF to upload it to your league's Stack Sports registration.

Privacy: This form runs in your browser. It does not send answers to a server or save them in browser storage. Avoid shared devices. Review the PDF before uploading. This is a locally generated reproduction of the official release, not an official Little League-hosted form.

1. Player and parent information

Player full name *

Date of birth *

Gender (M/F)

Parent/guardian name *

Relationship *

Second parent/guardian

Relationship

Player's street address *

City *

State/Country *

ZIP/postal code *

Home phone

Work phone

Mobile phone *

Parent email *

2. Physician, hospital and insurance

Family physician

Physician phone

Physician address

Physician city

Physician state/country

Hospital preference

Parent insurance company

Policy number

Group ID number

3. Emergency contacts

If parent(s)/legal guardian cannot be reached in an emergency:

Emergency contact 1 name *

Phone *

Relationship to player *

Emergency contact 2 name

Phone

Relationship to player

4. Medical information

Enter each diagnosis or allergy and its medication, dosage, and frequency on the same row. Up to four entries, as on the official form.

None — no known medical diagnoses, allergies, or medications

Medical diagnosis / allergies	Medication	Dosage	Frequency of dosage
Diagnosis / allergy row 1	Medication row 1	Dosage row 1	Frequency row 1
Diagnosis / allergy row 2	Medication row 2	Dosage row 2	Frequency row 2
Diagnosis / allergy row 3	Medication row 3	Dosage row 3	Frequency row 3
Diagnosis / allergy row 4	Medication row 4	Dosage row 4	Frequency row 4

If a medication is not applicable, leave its cells blank. For more than four conditions, ask the league how to provide a continuation sheet.

Date of last tetanus toxoid booster

Unknown

5. Authorization and signature

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)

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.

I am the player's parent/legal guardian, have reviewed the information above, and authorize the emergency treatment described. I intend my drawn signature below to represent my signature. *

Authorized parent/guardian full name *

Date *

Draw your signature below * (finger, stylus, or mouse)

The PDF is generated on your device; no form responses are sent to our server. Review the signed PDF before uploading to Stack Sports. A drawn signature is not a cryptographic digital signature; confirm acceptance with your league.