Sport :
Player Information Form
Personal Information:
Player Name ____________________________ ______ Fall
Class: (circle one) Fr
So
Jr
Sr
Spring Year: _____________________
Position(s) ____________________________________
Major/Minor __________________________________________________________________________
Height _________________
Weight______________
Date of Birth _____________________
Address:
Local Address _________________________________________________________________________
_______________________________________ ___________ Phone ____________________________
Home Address _________________________________________________________________________
_________________________________________________
Phone ____________________________
Email Address _________________________________________________________________________
Educational Background- School(s) Previously Attended:
High School _______________________________________
Date of Graduation ________________
Junior College _____________________________________
Date of Graduation ________________
Parent/Guardian Information:
Mother ________________________________
Father________________________________
Emergency Contact/Phone _______________________________________________________________
Address (if different from above) __________________________________________________________
Past Honors, Awards & Achievements: (both academic & athletic): may also use back
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Hometown Newspaper: _________________________________________________________________
PHOTOGRAPHIC CONSENT AND RELEASE FORM
I hereby authorize Utica College to:
(a)
Record my likeness and voice on a video, audio, photographic, digital, electronic or any
other medium (the "Recordings");
(b)
Use my name in connection with these Recordings;
(c)
Use, reproduce, exhibit, license or distribute, including to third parties, in any medium
(e.g. print publications, video tapes, CD-ROM, internet/world wide web) the Recordings
for any purpose that Utica College, and those acting pursuant to its authority, deems
appropriate, including promotional or advertising efforts concerning my participation in
intercollegiate athletics at Utica College consistent with NCAA regulations.
I hereby release and hold harmless Utica College, its trustees, officers, employees and agents, from any
and all causes of action for any violation of any personal or proprietary rights I may have in connection
with such use. I understand that all such Recordings, in whatever medium, shall remain the property of
Utica College.
I have read and fully understand the terms of this Consent and Release and verify the Consent and
Release is being made in furtherance of 34 CFR §99.30.
Name:
__________________________________________________________________
Address:
__________________________________________________________________
Street
__________________________________________________________________
City
State
Zip
Phone:
__________________________________________________________________
Signature:
___________________________________
Date:
________________________
Date:
________________________
Signature of Parent/Guardian if under 18:
___________________________________