LINCOLN HILLS SENIOR SOFTBALL LEAGUE
To facilitate provision of
medical care in case of injury or medical emergency during participation in
team games, the following information could 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 ˝”) 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
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NAME |
RELATIONSHIP |
TELEPHONE NO. |
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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.