PHI To
Selected Athletics Personnel
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 the Sports Medicine Staff of North Carolina State University Department of Athletics to release health information pertaining to my fitness to participate in NCSU intercollegiate Athletic activities to Athletic Department administrators, coaches, and administrative staff responsible for assessing or approving my participation to the extent the information is needed for that purpose.
_______________________________ ________________________________
Signature of Student Athlete Date