Permission to Share Information

You are a young adult. You are to take care of your own matters on campus. By law we are not allowed to share your information with others including parents. Coaches and the athletic administration will not discuss any of the following with anyone without your written permission:

• Grades

• Playing time

• Scholarships

• Behavior

• Financial Aid

• Eligibility

• Any other information related to you

Should you wish to allow our staff to speak with someone on your behalf, you must complete this form, have it notarized and return it to the Athletics Compliance Officer.

If you complete this form, have it notarized and return it to the Compliance Officer, we will be authorized to share any and ALL information concerning you.

Do not sign this form if that is not what you desire.

Upon completion of this form we will be authorized to share information ONLY with the individuals listed.

I, _____________________________, (Student’s PRINTED Name) wish to allow the athletic staff to share any and all information they have concerning me with the individuals identified below.

Individual 1: Name ___________________________ Relationship ___________________

Individual’s Place of Birth ______________________ Birth date ___________

Individual’s Favorite Color ________________

Individual 2: Name _________________________ Relationship _____________

Individual’s Place of Birth ____________________ Birth date ____________

Individual’s Favorite Color ___________________

Student’s Signature ____________________________ Date ______________

State of _________ County of __________

The above was acknowledged before me on ____________ by _______________.

(Signature of Notary) _____________________________________________

(Name of Notary Typed, Stamped, or Printed)) _______________________________________

(NOTARY SEAL)