Name, Image, & Likeness Disclosure Form

Name, Image, & Likeness Disclosure Form

Belmont University Athletics
For each name, image and likeness activity for which you have been or will becompensated, provide the following information:
Describe the compensated/non compensated name, image and likeness activity. What are/were the terms of the agreement or transaction? When will/did the activity begin and end?*
Describe the compensated/non compensated name, image andlikeness activity. What are/were the terms of the agreement or transaction? When will/did the activity begin and end?*

List all parties to the agreement or transaction, other individuals and entities, and professional service providers.*

	Name of Person/Entity	Role	Contact Information

I affirm, to the best of my knowledge:

o I have confirmed that this activity is consistent with state law/executive action and institutional policy. I understand that I am responsible for determining whether this activity is consistent with state law/executive action, if applicable, and that the NCAA will not interp state law/executive action and/or institutional policy.

o To the extent required by state law/executive action and/or institutional policy, I have provided complete and accurate information regarding any and all activities involving use of my name, image and likeness, including compensation arrangements and information about individuals and entities involved in the activity.

o Compensation was/is related to actual use of my name, image and likeness and was/is not contingent on enrollment at a particular institution or a substitute for pay for athletics performance.
I acknowledge that my institution, or a designee of my institution, may review the accuracy of this information, and I consent to any investigation, review, or audit. I acknowledge that inaccurate or incomplete disclosure, or failure to cooperate could support a reasonable conclusion that compensation I received constituted an inducement to attend or remain enrolled at a specific school, a substitute for pay for athletics performance or participation, or an otherwise illegitimate source of compensation for use of my name, image and likeness.
Signature of student-athlete*

Clear
Date*

MonthDayYear
Date
Signature of parent of legal guardian (if student-athlete is a minor)

Clear
Date

MonthDayYear
Date
In accordance with Tennessee law, any agreement entered into by an intercollegiate athlete under eighteen (18) years of age for the use of the athlete's name, image, or likeness must be in accordance with title 50, chapter 5, part 2.
Student-Athlete Name*
Student-Athlete Sport(s)*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Age*
Date of Birth*

MonthDayYear
Date
Should be Empty:

Name, Image, & Likeness Disclosure Form

For each name, image and likeness activity for which you have been or will becompensated, provide the following information: