FERPA Form for release of Student Athlete

PHI To the Media and Parent/Guardian

 

Office of Sports Medicine

AUTHORIZATION FOR RELEASE

OF HEALTH INFORMATION

 

 

Student-Athlete Name: ______________________________________________________________________________    

                                                First                                                       Middle Initial                                                       Last

 

Sport(s)  Men / Women  _______________________________________________

 

Date of Birth___/___/___         Age_______    Student ID#_____________________

 

 

I hereby grant permission to North Carolina State University Department of Athletics administrators and coaches to release to the news media the nature of any athletic-related injury or illness and my expected rehabilitation period, if any, for purposes of addressing my participation in intercollegiate athletic activities.  This information may also be released to my parent or guardian.

 

 

 

_______________________________          ________________________________

Signature of Student Athlete                                                      Date