Authorization to Release Information

 

 

 

 

I _________________________________________________________, HEREBY AUTHORIZE and request North Carolina State University Department of Athletics, and its duly authorized officers, employees and agents (including coaches, athletic trainers, and physicians) to furnish to all professional athletic teams, their scouts, representative agents, athletic trainers, physicians, employees, or agents, any and all records and information concerning or having a bearing on my participation in athletics at North Carolina State University. This authorization shall include, but is not limited to, any and all records and information within their knowledge, or contained in any records under their supervision or control concerning my physical condition, illnesses, injuries, and any treatment, hospitalization, surgery, examinations, X-rays, and otherwise, and to make such reports concerning myself to such persons or organizations as they may request.  

 

 

_______________________________                      __________________________

Signature of Student-Athlete                                       Date

 

 

I, AS THE PARENT/LEGAL GUARDIAN, have read the above Authorization to Release Information and I understand and agree to its terms.

 

 

_______________________________                      __________________________

Signature of Parent/Legal Guardian                           Date