AUTHORIZATION TO RELEASE INFORMATION by 27yaJCV

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									                AUTHORIZATION TO RELEASE INFORMATION

I, ____________________________, hereby authorize and request Washington
University in St. Louis, the Department of Athletics and their duly authorized agents,
servants or employees (including coaches, athletic trainers and physicians), to furnish to
all professional athletic teams, their scouts, representative agents, athletic trainers,
physicians, servants or employees, any and all information concerning or having bearing
upon my participation in intercollegiate athletics at Washington University in St. Louis.
Said authorization shall include, but is not limited to, any and all information within their
knowledge, or contained in any records under their supervision or control concerning
physical condition, illnesses, injuries, and any treatment hospitalization, examination, x-
rays, and otherwise, to make such reports to such persons or organizations, concerning
myself as they may request. I fully discharge all parties as listed above from a liability in
connection with the disclosure of medical information. I understand that treatment in the
training room may result in unavoidable disclosures of medical information to others in
the room due to the proximity of other athletes.

DATE____________ATHLETE’S NAME_____________________________________
                                            (print)
ATHLETE’S SIGNATURE_______________________________

PARENT OR GUARDIAN IF MINOR______________________


                AUTHORIZATION TO RELEASE INFORMATION

This is to authorize Washington University in St. Louis certified athletic trainers, team
physicians, and athletic coaches to release medical information related to my son or
daughter, or me, to Washington University in St. Louis Sports Information Department
and the various media outlets, any information concerning illness or injury relative to my
past, present, or future participations in intercollegiate athletics at Washington
University. I understand that treatment in the training room may result in unavoidable
disclosures of medical information to others in the room due to the proximity of other
athletes.

DATE____________ATHLETE’S NAME_____________________________________
                                            (print)

                       ATHLETE’S SIGNATURE_______________________________

                       PARENT OR GUARDIAN IF MINOR______________________

       *NOTE: Signatures on this form are valid for the duration of the student-athlete’s
involvement with the Department of Athletics. These releases may be withdrawn at any
time, by the student-athlete, in writing.

								
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