BRANDEIS SPORTS INFORMATION – RETURNING ATHLETE FORM

The information below is intended to aid the sports information office in promoting Brandeis Athletics to the best of its ability. It will be used to supply information to home-town newspapers in press releases; in pitching feature stories; in media guides; and on the Brandeis web site. The more we know about you, the better we can promote the University and its student-athletes!

NAME    CLASS

SPORT(S)

 

CONTACT INFO

 

Email address 

Cell Phone # 

HOME ADDRESS 

CITY     STATE  ZIP

Has your home address changed since last year? Yes No

ADDITIONAL INFO

 

Uniform # 

Position/event

Height

Weight

Major(s)

Minor(s)

If you are a member of any other organizations or clubs on campus, have participated in any community service activities, or hold any additional work-study jobs please list them here

If you have received any special academic awards, citations, or scholarships since coming to Brandeis or are involved in any interesting research, please describe here

If you have earned any athletic honors over the past year, please list them here



Describe your summer job and location



NOTE: This form comes under the purview of the Family Education Rights and Privacy Act of 1974.

PRINCIPAL SPECIFICATION OF RECORDS: This consent statement authorizes administrative personnel of Brandeis University to review and disseminate to third parties information in my personal “education records”, including information on this form and any other education information collected and/or maintained by this institution for public relations purposes.

PURPOSE(S) OF DISCLOSURE: Information obtained from these records will assist in compilation of personal information for use in official athletics department publications for dissemination to the news media, for purposes of nominating me for honors programs and scholarships and for general public relations purposes.

PARTY OR CLASS OF PARTIES TO WHOM DISCLOSURE MAY BE RELEASED: By checking the following box, I authorize administrative personnel of Brandeis University to review and disseminate any information in my “education records” to third parties for general public relations purposes.


DATE (MM/DD/YYYY) 

LAST FOUR DIGITS OF SAGE STUDENT ID #