CT Breeze
Medical Release Form

Athlete’s Name:  _________________________________________________________

Complete Address: _______________________________________________________

Home Phone: ________________                        Emergency Phone: ________________

Birth date: _________________________

Are you presently covered by health and accident insurance?        Ž Yes      Ž  No 

Insurance Company: ________________________________________

Insurance Number: _________________________________________

Please list below any medical problems concerning your athlete that we should know about:

I know that my participation in AAU sports activities is potentially hazardous and can cause bodily injury or death.  I clearly understand that, by signing this form and or my involvement in AAU sports activities, I assume all risk for any injury resulting there form.  I also give permission to allow emergency medical attention as needed.

____________________________      __________________________________

Athlete’s Signature                                  Parent Guardian Signature

  Ct Breeze, PMB 266, 800 Village Walk, Guilford, CT 06437 

Phone number:   1-203-494-8510