Player Name *

First Name

Last Name

Dominant hand: *

Left

Right

Would you like your club coach listed as a reference on your video? *

If yes, please enter information in next field.

Yes please

No thank you

Would you like your high school coach listed as a reference in your video? *

If yes, please enter information in next field.

Yes please

No thank you

Contact Information for the video: *

Would you like your player's contact information on the video?

Yes please

No thanks

Athlete's Release Form *

AUTHORIZATION TO USE OR RELEASE OF INFORMATION I/we hereby authorize Mercury Productions, Inc. to allow the reproduction, dissemination, and/or publication of my/our child's name and likeness for media coverage, public relations, or any other purpose which may involve the use of photographs, film, video or audio tape recording. This is to be done in conjunction with my/our child's participation with Mercury Productions, Inc.'s videotaping and editing service and creation of an online college recruiting skills/highlight video and/or any other related activity. I/we understand that I/we or my/our child will not be paid a fee, nor will I/we or my/our child receive any payment for the possible commercial use of my/our child's name or likeness.

I agree with this authorization and am at least 18 years old.

Date *

MM

DD

YYYY