PLAYMAKERS
Medical Release
TM
Name:*
Date of Birth:
League Name: Playmakers
Parent or Guardian Authorization:
In case of emergency, if family physician cannot be reached, I hereby authorize my child/ myself to be treated by Certified Emergency Personnel. (i.e. EMT, First Responder, E.R. Physician)
Family Physician:
Phone:
Address:
Hospital Preference:
In case of emergency contact:
Please list any allergies/medical problems, including those requiring maintenance medication. (i.e. Diabetic, Asthma, Seizure Disorder)
Medical Diagnosis/Allergies
Medication
Dosage
Frequency
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.
Date of last Tetanus Toxoid Booster:
WARNING: Protective equipment cannot prevent all injuries a player might receive while
participating in Baseball/Softbal/Basketball.
Playmakers does not limit participation in its activities on the basis of disability,
race, color, creed, national origin, gender, sexual preference or religious preference.