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Student Athlete Authorization for Release of Information to Media Mobile App

This authorization DOES NOT apply to the release of any records pertaining to psychiatric, psychological or psychotherapeutic services. I understand that I may revoke this authorization by providing a written revocation of authorization to the Program Coordinator that specifically mentions release of information to MEDIA, including journalists, reporters, sports information, or any other media outlet representatives. I understand that a revocation is not effective to the extent that the University has relied on this authorization to use or disclose any information about me.

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Take a peek inside the Student Athlete Authorization for Release of Information to Media Mobile App

Included Features

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Included Fields

Customize to add, remove, or edit any of the fields below.

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    I, (Student- Athlete Print Name)

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    HEREBY AUTHORIZE AND REQUEST the (university)

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    and their duly authorized officers, employees and agents (including coaches, athletic trainers, p...

  • Ico statictext

    This authorization DOES NOT apply to the release of any records pertaining to psychiatric, psycho...

  • Ico statictext

    I understand that a record will be kept of all individuals requesting information under this Auth...

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    his Authorization remains valid for [check one]:

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    one (1) year following the date I sign below;

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    Or to this date.

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    I understand that I may revoke this authorization by providing a written revocation of authorizat...

  • Ico statictext

    I hereby fully release and discharge the University Board of Trustees and all its successors, ass...

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    Student-Athlete Signature

  • Ico date

    Date

  • Ico textbox

    Witness Print Name

  • Ico signature

    Witness Signature

  • ...and More!

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