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NOTE: To by Regular Tournament Banneker Little League® Softbol or Revelación Médica NOTE:Ciudad To be be carried carried by any any Béisbol RegularySeason Season or Tournament Team Manager together with team roster or International Tournament Team Manager together with team roster or International Tournament affidavit. affidavit. NOTE: To be carried by any Regular Season or Tournament Team Manager together with team roster or International Tournament affidavit. NOTA: A llevarse a cabo por cualquier Temporada Regular o DirigenteDate del Equipo Torneo junto con el róster del equipo o declaración jurada de elegibilidad. Player: of ____________ Gender (M/F):_________________ Player: _____________________________________ _____________________________________ Date ofdelBirth: Birth: ____________ Gender (M/F):_________________ Player: _____________________________________ Date of Birth: ____________ Gender (M/F):_________________ Parent Relationship:____________________________ Fecha de Nacimiento Sexo Jugador (s)/Guardian Parent (s)/Guardian Name:_____________________________________ Name:_____________________________________ Relationship:____________________________ Parent (s)/Guardian Name:_____________________________________ Relationship:____________________________ Parent (s)/Guardian Relationship:____________________________ del Padre/Tutor:Name:_____________________________________ con el Jugador ParentNombre (s)/Guardian Name:_____________________________________Relación Relationship:____________________________ Parent (s)/Guardian Name:_____________________________________ Relationship:____________________________ Player’s Address:____________________________________ City:_______________ Nombre del Padre/Tutor: Relación con el JugadorState/Country:________ Player’s Address:____________________________________ City:_______________ State/Country:________ Zip:______ Zip:______ Player’s Address:____________________________________ City:_______________ State/Country:________ Zip:______ Home Work Mobile Estado Domicilio dePhone:_____________________ Jugador Ciudad Código Home Phone:_____________________ Work Phone:______________________ Phone:______________________ Mobile Phone:_____________________ Phone:_____________________ E-Mail: Home Phone:_____________________ Work Mobile Phone:_____________________ Cell Phone:______________________ Phone: PaRent oR Número de casa Número de móvil Correo electrónico PaRent oR GuaRdian GuaRdian authoRization: authoRization: Autorización del Padre o Tutor: PaRentofoR GuaRdianfamily authoRization: In In case case of emergency, emergency, if if family physician physician cannot cannot be be reached, reached, II hereby hereby authorize authorize my my child child to to be be treated treated by by Certified Certified Emergency Personnel. (i.e. EMT, First Responder, E.R. Physician) Emergency Personnel.if(i.e. EMT, First Responder, E.R. Physician) In case of emergency, family physician cannot be reached, I hereby authorize my child to be treated by Certified En caso de emergencia, si no se puede llegar al médico familiar, Yo, por la presente autorizo que mi hijo sea tratado por el Personal de Emergencia Certificado. (es decir, TME, Primeros Auxilios, Médico de Emergencia) Emergency Personnel. (i.e. EMT, First Responder, E.R. Physician) Family Physician: Physician: ____________________________________________ Phone: _________________________________ _________________________________ Family ____________________________________________ Phone: Family Physician: ____________________________________________ Phone: _________________________________ Address: __________________________________________ City:________________ State/Country:_________________ Teléfono Médico Familiar__________________________________________ Address: City:________________ State/Country:_________________ Address: __________________________________________ City:________________ State/Country:_________________ Hospital Preference: __________________________________________________________________________________ Dirección Estado Ciudad Hospital Preference: __________________________________________________________________________________ Hospital Preference: __________________________________________________________________________________ Parent Insurance Co:_________________________ Co:_________________________ Policy Policy No.:__________________Group No.:__________________Group ID#:_____________________ ID#:_____________________ Hospital de Preferencia Parent Insurance Parent Insurance Co:_________________________ Policy No.:__________________Group ID#:_____________________ League Insurance Co:_________________________Número Policy No.:__________________League/Group ID#:______________ Compañía deInsurance seguros paternalCo:_________________________ Número id de grupo de póliza League Policy No.:__________________League/Group ID#:______________ League Insurance Co:_________________________ Policy No.:__________________League/Group ID#:______________ if parent(s)/guardian parent(s)/guardian cannot be be reached reached in in case case of of emergency, emergency, contact: Número de póliza contact: Número id de grupo/Liga Compañía de seguros Liga if cannot if parent(s)/guardian cannot be reached in case of emergency, contact: En caso de emergencia contactar a: ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ Name Phone Relationship to to Player Player Name Phone Relationship ___________________________________________________________________________________________________ Name Phone Relationship to Player ___________________________________________________________________________________________________ Nombre Teléfono Relación con el Jugador ___________________________________________________________________________________________________ Name Phone Relationship to to Player Player Name Phone Relationship ___________________________________________________________________________________________________ Namelist any allergies/medical problems, including those requiringPhone Relationship to Player Please maintenance medication. (i.e. Diabetic, Asthma, Seizure Disorder) Teléfono Nombre list any allergies/medical problems, including those requiring maintenance medication. (i.e. Diabetic, Relación conAsthma, el Jugador Seizure Disorder) Please Por favor liste cualquier alergia/problema médico, incluyendo aquellos que requieran medicamentos permanentes. (es decir, Diabético, Asma, Trastorno de Convulsión) Medical Diagnosis Medication Dosage of Please list any allergies/medical requiring maintenance medication. Asthma, Seizure Disorder) Medical Diagnosis problems, including those Medication Dosage(i.e. Diabetic,Frequency Frequency of Dosage Dosage Diagnóstico Médico
Medical Diagnosis
Medicamentos
Medication
Dosificación
Dosage
Frecuencia de Dosificación
Frequency of Dosage
Date Date of of last last Tetanus Tetanus Toxoid Toxoid Booster: Booster: ______________________________________________________________________ ______________________________________________________________________ Date of last Tetanus Toxoid Booster: 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. Fecha la última of dosis deabove refuerzolisted de toxina del tétano is to ensure that medical personnel have details of any medical problem which may interfere with or alter treatment. The de purpose the information
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. Mr./Mrs./Ms. ________________________________________________________________________________________ El propósito de la información listada arriba es asegurar que el personal médico tenga detalles de cualquier problema médico el cual pueda interferir con o alterar el tratamiento. Mr./Mrs./Ms. ________________________________________________________________________________________ Authorized Parent/Guardian Date: Authorized Parent/Guardian Signature Signature Date: Mr./Mrs./Ms. ________________________________________________________________________________________ Sr./Sra./Srta. Authorized Parent/Guardian Signature Date: Firma del Padre/Tutor Autorizado
Fecha
FoR LeaGue LeaGue uSe uSe onLY: onLY: FoR FoR LeaGue uSe onLY: Banneker City 220-03-260023 League Name:_______________________________________________ League ID:________________________________ ID:________________________________ League Name:_______________________________________________ League League Name:_______________________________________________ League ID:________________________________ Division:_________________________________Team:______________________________ Date:____________________ Division:_________________________________Team:______________________________ Date:____________________ WARNING: PRoTECTIvE EquIPMENT CANNoT PREvENT ALL INjuRIES A PLAyER MIGHT RECEIvE WHILE PARTICIPATING IN BASEBALL/SoFTBALL. Division:_________________________________Team:______________________________ Date:____________________ WARNING: PRoTECTIvE EquIPMENT CANNoT PREvENT ALL INjuRIES A PLAyER MIGHT RECEIvE WHILE PARTICIPATING IN BASEBALL/SoFTBALL. Little League does not limit participation in its activities on the basis of disability, race, color, creed, national origin, gender, sexual preference or religious preference. Little League does not limit participation in its activities on the basis of disability, race, color, creed, national origin, gender, sexual preference or religious preference.
PRECAUCIÓN El equipo de protección no puede prevenir todas las lesiones que un jugador podría recibir durante la participación en Béisbol/Softbol. WARNING: PRoTECTIvE EquIPMENT CANNoT PREvENT ALL INjuRIES A PLAyER MIGHT RECEIvE WHILE PARTICIPATING IN BASEBALL/SoFTBALL. Pequeñas Ligas no limita la participación en sus actividades sobre base derace, discapacidad, raza, color, credo,origin, origen nacional, sexual o religiosa.preference. Little LeagueLas does not limit participation in its activities on the basis of una disability, color, creed, national gender, género, sexual preferencia preference or religious
