Cleveland State University Sports Information Questionnaire

Name: 
Email:
Phone:
Date & Location of Birth:
Hometown (City, State or City, Country):
High School Attended:
Height: Weight: Right or Left Footed:
Academic Major:

Family Information
Father’s Full Name:
Mother’s Full Name:
Legal Guardian (if not a parent): 
On Your Bio, how do you want your parents listed:
List the names & ages of any Brothers:
List the names & ages of any Sisters:
Any relatives who have been or are currently in college or professional athletics: 

Non-Athletic Information
High School Academic Honors:
High School Activities besides athletics: 

Athletic Information - High School Team

High School Conference (Do Not Abbreviate):
High School Nickname/Mascot:
Athletic Achievements & Honors (And/or Team Achievements) for High School Team:

Statistics compiled for high school team:

Athletic Information – Club Team (Non-School Team)

Non-School and/or Club Team Name(s):
List Years Spent With Each Club (If More Than One):
Achievements/Impressive Performances with Club Team:

Permission for Release of Information

I, the undersigned, authorize permission to the Cleveland State University Athletic Department to release my intercollegiate participatory
sports records to the media requesting such information for publication or other use. I further authorize this institution to release such
information which may include records earlier forwarded to this institution from high schools/junior colleges attended by me, to the media by
the CSU Sports Information Office. The released information may include any of the following: actual game participation statistics; pertinent
personal data such as height, weight, position, age, hometown, college class status and past schools attended; athlete’s comments for use in
personal feature articles and photographs or films; pertinent medical information in consultation with the team trainer/doctor and coach.
Excluded from the information for release are any academic records other than those of a positive nature such as for promotion with the mass
media for conference or national athletic-academic honors.

(Student-Athlete Signature) (Date)

This release is given at the request of guidelines imposed by the Education Rights and Privacy Act of 1975