REDWOOD FASTPITCH ASA SOFTBALL

2016 Medical Release

NOTE: To be carried by any Regular Season Coach or Tournament Team Manager together with team roster.

Player Name :

Date of Birth:

League Name: REDWOOD FASTPITCH ASA SOFTBALL

Parent or Guardian Authorization:
I/we the undersigned certifies that his/her child is in good health and able to participate in all
softball activities. I assume and agree to hold harmless, Redwood Fastpitch, and any other
parties, firms, or organizations from any and all claims by reason of accident, illness, injury,
death, or other consequences as a direct or indirect result of playing recreational softball for
Redwood Fastpitch.
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)
Family Physician:

Phone:

Address:
Hospital Preference:
IN CASE OF EMERGENCY PARENTS ARE THE FIRST ONES CONTACTED.
In you would like any additional emergency contacts:
Name:

Phone:

Relationship:

Name:

Phone:

Relationship:

Please list any allergies/medical problems, including those requiring maintenance medication.
(i.e. Diabetic, Asthma, Seizure Disorder)
Medical Diagnosis

Medication

Dosage

Frequency 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 treatment.
Date of last Tetanus Toxoid Booster:
Authorized Parent/Guardian Signature: ____________________________________

Date: ____________________________