department of athletics policies & procedures - UNC Wilmington ...

FERPA Form for release of Student-Athlete
PHI to the Parent/Guardian
University of North Carolina Wilmington
Department of Athletic Training
Authorization for Release of Health Information
Student-Athlete Name
(First) (MI) (Last)
Sport(s) Men’s/Women’s
Date of Birth / / Age UNCW ID#
I hereby grant permission to the University of North Carolina Wilmington Department of
Athletic Training Staff to release the nature of any injury or illness, athletic-related or
otherwise, and expected treatment or rehabilitation protocols to the parents/legal guardians
listed below.
Relationship to Student-Athlete
(print Parent/Guardian name)
Relationship to Student-Athlete
1