University Of Hawaii-Hilo
Athletes Personal Information
Name _________________________________ Sport ___________________________
Student ID of Social Security # ______________________________ DOB ___/___/___
Local Home Address _____________________________________________________
City __________________________ State ___________________ Zip ______________
Local Phone # __________________________________________
Parents/Home Address ____________________________________________________
City __________________________ State ___________________ Zip ______________
Home Phone # _________________________________________
Emergency Contact Information
Name ________________________________ Relationship ______________________
Phone # (H) __________________ (W) __________________ ( C)_________________
Insurance Information
Insurance Company _______________________________________________________
Policy Holder ____________________________________________________________
Group # _____________________________ Policy # ___________________________
Phone #______________________________________________
Signature ____________________________________________ Date ______________
Signature
Parent/Legal Guardian __________________________________ Date ______________
Student-Athlete Supplement Notification
I, __________________________________, acknowledge that I am currently taking and/or have (within the past 6 months) taken the following ergogenic aids, creatine powder, amino acids, protein, supplements, or other similar substances, hereinafter referred to as “Supplements.”
(Use the back of this form if necessary)
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I understand and agree:
a) The University of Hawaii-Hilo Department of Intercollegiate Athletics neither approves of nor condones the use of Supplements.
b) I have been informed of the University of Hawaii-Hilo Department of Intercollegiate Athletics, and the National Collegiate Athletic Association (NCAA), policies with regards to the use of Supplements, and have had any questions about these policies answered:
c) The use of Supplements may result in serious harm to me, possible permanent injury to my health, and even death.
d) I risk losing my eligibility to participate in intercollegiate athletics if I test positive for an NCAA banned substance:
e) I must list all Supplements on the Chain of Custody Forms at the time of any drug test.
I fully accept any and all risks and liability if I have used in the past, continue to use, or use at anytime in the future any form of Supplements.
I further understand and agree the University of Hawaii-Hilo, its officers, employees, and agents are not responsible for any harm and possible permanent injury to my health caused by my past, and/or future use of Supplements. I agree to hold harmless, indemnify, and irrevocably and unconditionally release the State of Hawaii, the University of Hawaii-Hilo, and their officers, employees and agents from any and all liability, and demands, claims and causes of action relating to my use of Supplements.
I understand the statements in this form, and have had all questions about the information in this form answered to my satisfaction.
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Student-Athlete’s Signature Date
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Parent/Guardian’s Signature (if under 18 yrs old) Date
