LINCOLN HILLS SENIOR SOFTBALL LEAGUE

Medical Information for Emergency

To facilitate provision of medical care in case of injury or medical emergency during

participation in team games the following information will be of great importance. The

information provided is voluntary and will remain in a binder located at the field. If you

prefer to keep this information confidential, please seal this page in a standard (4”x 9 ½”)

envelope, and it will be opened only if needed by Emergency Medical personnel. Please

print your name on the outside of the envelope.

NAME (Print)

PERSON OR PERSONS TO BE NOTIFIED IN CASE OF EMERGENCY

NAME

RELATIONSHIP

TELEPHONE NO.

MEDICATION PRESENTLY TAKEN

ALLERGIES, INCLUDING MEDICATION

HEALTH INSURANCE PLAN __________________________

DOCTOR’S FULL NAME TELEPHONE NO.

HOSPITAL PREFERENCE BLOOD TYPE (IF KNOWN)

RUNNER REQUIRED FROM HOME PLATE (DOCTOR’S NOTE REQUIRED) Yes ________

SIGNATURE DATE

Please disclose and list any other medical problems, devices, or concerns that would aid

Emergency Medical personnel in the event of a medical emergency (example: pacemaker,

implants, internal defibrillator, etc.)

The LHSSL assumes no liability and participates in the role of Good Samaritan.

The LHSSL does not provide medical insurance.