Spring Hill College Athletics Department

Transcription

1 Spring Hill College Athletics Department STUDENT-ATHLETE PARTICIPATION FORM Academic Year CHECK HERE IF FIRST TIME AT SHC CHECK HERE IF UNDER 19 PERSONAL INFORMATION Please Print Clearly Sport(s) Name Last First MI SHC ID # Sex M/F DOB / / SHC Address: (please print clearly!) Cell Phone: SHC Address OR Dorm and Room No. Street Apt. No. City State Zip Home Address Street Apt. No. A Parent s Cell City State Zip First and Last name of living father and mother OR name of legal guardian(s) If parents are T living together a) Which parent has legal responsibility for you? b) Name and address of parent you want mailings sent to (if different from above): FATHER: MOTHER: Have you ever served in the military? Yes No If yes, please give month/year entered and month/year of discharge Please indicate your race/ethnicity: Foreign National/Alien Black/African-American Hispanic/Latino White/Caucasian/Non-Hispanic Asian American Indian/Alaskan Native Pacific Islander/Hawaiian Two or more Races Unknown

2 Student-Athlete Financial Aid Information (1) During this academic year, are you receiving or have arrangements been made for you to receive an athletics scholarship at SHC? (2) Will you be receiving any other financial aid, scholarship or employment earnings, including money or other material benefits? If, please state the approximate amount and the terms of such additional aid: (3) Have you received or will you receive any athletics equipment, apparel, supplies or prizes from any source other than your high school or SHC? If, please name the person/organization providing the items: If, describe the equipment, apparel, supplies or prizes: (4) At the present time, will anyone other than yourself receive any money, credits, loans, trust funds, insurance policies, property or benefits on account of your attendance at SHC or your participation in intercollegiate athletics? If, name anyone who is receiving such benefits: If, describe such benefits: If, name the source of such benefits: OUTSIDE SCHOLARSHIPS Please give the following information for each outside scholarship you will be receiving during the academic year. Include all awards except SHC athletic aid, institutional grants, and Pell Grants. (For example: Elks Lodge, High School Booster Club, Ford Scholarship, etc.) Name of Award: Organization: $ Name of Award: Organization: $ Name of Award: Organization: $ It is your responsibility to notify the Compliance Office if you receive an outside award after this declaration.

3 Automobile Information *Do you have the use of a motor vehicle? If you answered to the question above, please skip the remainder of the Automobile questions. *ONLY To Be Completed By Student-Athletes With Use Of A Car Year: Make: Model: Color: State of Registration: Car Owner & Relationship to You: When was the car purchased?: From Who?: From Where?: Was any SHC coach, staff member or booster involved in the purchase? *If, please describe the situation: Is there an outstanding loan on the automobile? *IF, who makes the loan payments? Who pays the insurance premiums? What is the relationship of that person to you? Who pays for the maintenance (e.g. oil change, tune-ups)? Who pays for the gasoline? Student-Athlete Housing Information Form *ONLY To Be Completed By Student-Athletes Living Off-Campus: (1) Please check where you currently live: Apartment Fraternity/Sorority House Parents *Please list the name of the complex/organization: (2) How did you find this residence? Classmates Teammates Advertisement Alumni or Booster Other please explain: (3) If you are paying rent, do you share the residence? *If, please list with whom you share it: (4) What is your monthly rent and deposit? What is the length of your lease? (5) Who is paying your rent?

4 Statement of Amateurism NCAA rules prohibit professional athletes from competing in intercollegiate athletics. These questions are meant to help verify that student-athletes have not become a professional and also to help inform student-athletes of the types of actions that will put their eligibility in jeopardy. Please answer the following questions by circling or : 1 Have you ever used your athletics ability to earn salary, benefits, cash? 2 Have you ever accepted a promise of pay to be received following completion of your college eligibility? 3 Have you ever signed a contract or entered into an oral agreement of any kind in regard to professional athletics? 4 Have you ever received pay, financial assistance or consideration from a professional sports organization? 5 Have you ever played or practiced with any team with professional athletes? 6 Have you ever entered into a professional sports draft? 7 Have you ever had a tryout with a professional sports team? 8 Have you ever had a physical examination conducted by a professional sports team during the academic year while you still had eligibility remaining? 9 Has any SHC coach, staff member or booster ever allowed you to use a vehicle? If, please describe: 10 Have you ever played in any event where the participants were paid? 11 Have you ever received expenses to cover development training, coaching, equipment, apparel, supplies, insurance, travel or accommodations? 12 If your answer to question #11 was, were the expenses provided by the USOC or the national governing body of the sport? 13 Did you participate in outside competition during summer 2016? If, what team did you participate on or what race events did you participate in? If, who paid your expenses? Did you receive any prizes, awards or cash for participating in these competitions? If, please list: 14 Have you ever been paid for teaching or coaching sports skills in your sport on a fee-for-lesson basis ( private lessons ) during your time in college? 15 Have you ever been paid to serve as an official or referee with a professional sports organization? 16 Have you ever permitted the use of your name or picture in advertisements for promotional purposes? 17 Have you ever received any pay or other compensation for appearing on TV or radio? 18 Have you ever publicly endorsed or promoted products or services without identifying yourself by name or as a member of a SHC team?

5 General Compliance Questions 1. Do you know of any Conference or NCAA rule violations that have taken place during your recruitment or while enrolled at SHC? If, please explain: 2. Are you aware that you could lose eligibility permanently if you gamble on intercollegiate athletics events or professional events that are sponsored at the collegiate level? This includes betting on games with bookies, your friends, boosters, faculty or any other individual. 3. Are you aware that certain supplements, prescriptions and over-the-counter medications contain substances that may be banned by the NCAA? Testing positive for such substances could cause you to lose athletics eligibility for one or more years. (Please see you athletics trainer or the Compliance Office for more information.) (Returning SA s) Did SHC coaches exceed daily (i.e., 4 hr per day) or weekly (i.e., 20 hrs during season/8 hrs out of season) practice limitations during the academic year? If yes, please identify when? I certify that my answers are complete and accurate. I understand that any false or incomplete statements in this document may make me ineligible for intercollegiate athletic competition, and/or any athletic scholarship at Spring Hill College. Signature

6 Consent to Release of Education Records Under the Family Educational Rights and Privacy Act of 1974, I understand that my educational records cannot be released without my written permission or proof of dependency by my parent or guardian. I hereby authorize Spring Hill College to release any and all information from my educational records in order to allow recognition of my accomplishments as an outstanding student-athlete to representatives of recognizing entities and organizations, and/or representatives of the news media as is deemed appropriate by SHC in its sole discretion. The information that may be released by SHC includes, but is not limited to, my grade point average, my major, any honors I have received, my progress toward or acquirement of a degree, and my athletics accomplishments. Additionally, I hereby authorize SHC to disclose any and all information from my educational records regarding any violation of NCAA, the Gulf South Conference, Southern Intercollegiate Athletic Conference or SHC rules or regulations while a student-athlete to third parties (including, but not limited to, representatives of the news media) as is deemed appropriate by SHC in its sole discretion. The information that may be released by SHC includes the nature and extent of any violation and any resulting disciplinary action taken against me. Additionally, I hereby authorize SHC to disclose personally identifiable information from my educational records to my parents or legal guardians. A photocopy of this authorization is as valid as the original. This release is valid during the following period only: August 1, 2016 July 31, 2017 Signature of Student-Athlete Printed Name of Student-Athlete Student-Athlete Institutional Promotional Authorization I hereby grant the Spring Hill College Athletic Department, and all its agents, employees and representatives, permission to use my name, image, likeness, and/or voice for the purpose of advertising or promoting the College in any print or electronic media. I agree that Spring Hill College will have final authority, and I waive the right to inspect or approve the finished product before use. I further agree that any reproduction of my likeness becomes the exclusive property of the College. I acknowledge that no fee nor compensation shall be paid to me, nor to anyone associated with me for giving my permission to the College for the purposes stated above. I release and fully discharge Spring Hill College, and its agents, employees and representatives, from any claim, damages, or liability arising from or related to, or my participation in any way, shape or form now and/or in the future. A photocopy of this authorization shall be as valid as the original. This release is valid during the following period only: August 1, 2016 through July 31, 2017 Signature of Student-Athlete Printed Name of Student-Athlete Signature of Parent/Guardian (if student-athlete is under 19)

7 Spring Hill College Student-Athlete Employment During Do you, or will you have a job on campus this year? Yes No Do you, or will you have a job off campus this year? Yes No NCAA rules and regulations permit student-athlete to be employed during the academic year; however, all compensation received by a student-athlete must be consistent with the following limitation: It must be for work actually performed; and At a rate commensurate with the going rate in the locality for similar services. Prior to starting on- or off-campus employment, I agree to do the following: 1. See the compliance office for prior approval (before you start work!); 2. Return a completed student/employer verification form to the compliance office; 3. Provide compliance office with pay stub (as requested by compliance). I am aware that failure to follow the above process could cause me to be ineligible for practice and/or competition. Sign: :

8 Form 16-3b Academic Year: Student-Athlete Statement NCAA Division II For: Student-athletes. Action: Sign and return to your director of athletics or director of athletics designee. Due date: Before your first competition each year. Required by: NCAA Constitution and NCAA Bylaw Purpose: To assist in certifying eligibility. Effective date: This NCAA Division II Student-Athlete Statement/Drug- Testing Consent form shall be in effect from the date this document is signed and shall remain in effect until a subsequent NCAA Division II Student-Athlete Statement/ Drug-Testing Consent form is executed. Student-Athlete: (Please print name) Name of your institution: Sport: This form has five parts: a statement concerning eligibility, a Buckley Amendment consent, results of drug tests, an affirmation of a valid ACT or SAT score and a statement concerning the amateur status of the student-athlete subsequent to the request of final certification by the NCAA Eligibility Center. If you are an incoming freshman you must sign parts I through V of this form to participate in intercollegiate competition. If you are a transfer or continuing student-athlete, you must sign parts I through IV. By signing this form, you affirm you have received and will read the Summary of NCAA Regulations, or another outline or summary of NCAA legislation, provided by your director of athletics, or read the bylaws of the NCAA Division II Manual that deal with your eligibility. You are responsible for knowing and understanding the application of all NCAA Division II bylaws related to your eligibility. If you have any questions, you should discuss them with your director of athletics, or you may contact the NCAA at or consult the NCAA website at The conditions that you must meet to be eligible and the requirement that you sign this form are indicated in the following articles and bylaws of the Division II Manual: NCAA Constitution and NCAA Bylaws , and

9 Form 16-3b Page No. 2 Part I: Statement Concerning Eligibility. You affirm that you have been provided and will read the Summary of NCAA Regulations, or another outline or summary of NCAA legislation, or the relevant sections of the Division II Manual and that your director of athletics (or his or her designee) gave you the opportunity to ask questions about the regulations. You affirm that you have knowledge of and understand the application of NCAA Division II bylaws related to your eligibility. By signing this part of the form you affirm that, to the best of your knowledge, you have not violated any NCAA regulations. You affirm that you meet the NCAA regulations for student-athletes regarding eligibility, recruitment, financial aid, amateur status and involvement in organized gambling. You affirm that you are aware of the NCAA drug-testing program and that you have signed the Drug-Testing Consent (Form No. 16-3e). You affirm that you will report to the director of athletics of your institution any violations of NCAA regulations involving you and your institution. You affirm that you understand that if you sign this statement falsely or erroneously, you violate NCAA legislation regarding ethical conduct and you further will jeopardize your eligibility. Name of student-athlete (please print) of birth Age Signature of student-athlete Home address (street or P.O. Box) Home city, state, and ZIP code Sport(s)

10 Form 16-3b Page No. 3 Part II: Buckley Amendment Consent. By signing this part of the form you certify that you agree to disclose your education records. You understand that this entire form and the results of any NCAA drug test you may take are part of your education records. These records are protected by the Family Educational Rights and Privacy Act of 1974 and they may not be disclosed without your consent. You give your consent to disclose only to authorized representatives of this institution, its athletics conference (if any) and the NCAA, the following documents: 1. This form; 2. Results of NCAA drug tests and related information and correspondence; 3. Results of positive drug tests administered by a non-ncaa national or international sports governing body; 4. Any transcript from your high school, this institution or any two-year college or other four-year institution you have attended; 5. Precollege test scores, appropriately related information and correspondence (e.g., testing sites, dates and letters of test-score certification or appeal) and, where applicable, information relating to eligibility for or conduct of nonstandard testing; 6. Graduation status; 7. Race and gender identification; 8. Diagnosis of any education-impacting disabilities; 9. Accommodations provided or approved and other information related to any educationimpacting disabilities in all secondary and postsecondary schools; 10. Records concerning your financial aid; and 11. Any other papers or information pertaining to your NCAA eligibility. You agree to disclose these records only to determine your eligibility for intercollegiate athletics, your eligibility for athletically related financial aid, for evaluation of school and team academic success, for awards and recognition programs highlighting student-athlete academic success, for purposes of inclusion in summary institutional information reported to the NCAA (and which may be publicly released by it), for NCAA longitudinal-research studies and for activities related

11 Form 16-3b Page No. 4 to NCAA compliance reviews. You will not be identified by name by the NCAA in any such published or distributed information. Further, you authorize the NCAA to disclose personally identifiable information from your educational records (including information regarding any NCAA violations in which you may become involved while you are a student-athlete) to a third party (including but not limited to the media) as necessary to correct inaccurate statements reported by the media or related to a student-athlete reinstatement case, infractions case or waiver request or to recognize your selection for an academic award (e.g., Elite 89). You also agree that necessary case information (i.e., information from your student-athlete reinstatement case, infractions case or waiver request) may be published or distributed to third parties as required by NCAA bylaws, policies or procedures. You will not be identified by name by the NCAA in any such published or distributed information. Name of student-athlete (please print) Signature of student-athlete

12 Form 16-3b Page No. 5 Part III: Results of Drug Tests. 1. Future positive test all student-athletes sign. Should I test positive for a substance banned by the NCAA and/or by a non-ncaa athletics organization, or violate a drug-testing protocol or fail to show for a drug test at any time after I sign this statement, I acknowledge I must report the results to my director of athletics. Name of student-athlete (please print) Signature of student-athlete 2. Positive test by NCAA or other sports governing body -- sign either a or b. a. No positive drug test. I affirm that, as part of an NCAA or non-ncaa athletics organization drug test, I have never tested positive for a substance banned by the NCAA and/or by a non- NCAA athletics organization and have never violated a drug-testing protocol or failed to show for a drug test. Name of student-athlete (please print) Signature of student-athlete

13 Form 14-3b Page No. 6 b. Positive drug test. I have tested positive, as part of an NCAA or non-ncaa athletics organization drug test, for a substance banned by the NCAA and/or by a non-ncaa athletics organization, or have violated a drug-testing protocol or failed to show for a drug test. If I transfer to another instituton, I am also obligated to report this information to that institution. Name Signature of test Organization conducting test Substance Are you currently under such a drug-testing suspension? Yes No

14 Form 16-3b Page No. 7 Part IV: Affirmation of Status as an Amateur Athlete. You affirm that you have read and understand the NCAA amateurism rules. By signing this part of the form you affirm that, to the best of your knowledge, you have not violated any amateurism rules since you requested a final certification from the Eligibility Center or since the last time that you signed a Division II student-athlete statement, whichever occurred later. You affirm that since requesting a final certification from the Eligibility Center, you have not provided false or misleading information concerning your amateurism status to the NCAA, the Eligibility Center and the institution's athletics department, including administrative personnel and the coaching staff. Name of student-athlete (please print) Signature of student-athlete Part V: Incoming Freshmen Affirmation of Valid ACT or SAT Score. You affirm that, to the best of your knowledge, you have received a validated ACT and/or SAT score. You agree that, in the event you are or have been notified by ACT or SAT of the possibility of an invalidated test score, you immediately will notify the director of athletics of your institution. Name of student-athlete (please print) Signature of student-athlete What to do with this form: Sign and return it to your director of athletics before your first competition. This form is to be kept in the director of athletics' office for six years. Any questions regarding this form should be referred to your director of athletics or you may contact the NCAA at NCAA/06_06_2016/AT:kas

15 Form 16-3e Academic Year: Drug-Testing Consent NCAA Division II For: Student-athletes. Action: Sign and return to your director of athletics. Due date: At the time your intercollegiate squad first reports for practice or the first day of competition or before the Monday of the fourth week of classes, whichever is earlier. Required by: NCAA Constitution and NCAA Bylaw Purpose: To assist in certifying eligibility. Effective date: This consent form shall be in effect from the date this document is signed and shall remain in effect until a subsequent Drug-Testing Consent Form is executed. Requirement to Sign Drug-Testing Consent Form. Name of your institution: Name of student-athlete: Sport(s): You must sign this form to participate (i.e., practice or compete) in intercollegiate athletics per NCAA Constitution and NCAA Bylaw If you have any questions, you should discuss them with your director of athletics. Consent to Testing. You agree to allow the NCAA to test you on a year-round basis and in relation to any participation by you in any NCAA championship and in any postseason football game certified by the NCAA for the banned drugs listed in Bylaw (Attachment). Examples of drugs under each class can be found at Note: There is no complete list of banned substances. Check the Resource Exchange Center for questions about supplements, medications and banned drugs. Consequences for a Positive Drug Test. By signing this form, you affirm that you are aware of the NCAA drug-testing program, which provides: 1. A student-athlete who tests positive for an NCAA banned drug must immediately be declared ineligible. 2. A student-athlete who tests positive for a banned drug other than a street drug shall be withheld from competition in all sports for a minimum of 365 days from the drug-test collection date and shall lose a year of eligibility. A student-athlete who tests positive for a street drug shall be withheld from competition for 50 percent of a season in all sports (at least the first 50 percent of all contests or dates of competition in the season following the positive test); 3. A student-athlete who tests positive has an opportunity to appeal the sanctions resulting from the positive drug test. 4. A student-athlete who tests positive a second time for the use of any drug other than a street

16 Form 16-3e Page No. 2 drug shall lose all remaining regular-season and postseason eligibility in all sports. A studentathlete who tests positive a second time for a street drug shall be withheld from competition for 365 days from the date of the test and shall lose an additional year of eligibility; 5. The penalty for missing a scheduled drug test is the same as the penalty for testing positive for the use of a banned drug other than a street drug. 6. A student-athlete found to have tampered with an NCAA drug-test sample shall be charged with the loss of a minimum of two seasons of competition in all sports and shall remain ineligible for all regular-season and postseason competition during the time period ending two calendar years (730 days) from the date of the test. 7. If a student-athlete transfers to a non-ncaa institution while ineligible because of a positive NCAA drug test, and competes in collegiate competition within the prescribed penalty at a non- NCAA institution, the student-athlete will be ineligible for all NCAA regular-season and postseason competition until the student-athlete does not compete in collegiate competition for the entirety of the prescribed penalty. Signatures. By signing below, I consent: 1. To be tested by the NCAA in accordance with NCAA drug-testing policy, which provides among other things that: a. I will be notified of selection to be tested; b. I must appear for NCAA testing or be sanctioned for a positive drug test; and c. My urine sample collection will be observed by a person of my same gender; 2. To accept the consequences of a positive drug test or a breach of drug testing protocol; 3. To allow my drug-test sample to be used by the NCAA drug-testing laboratories for research purposes to improve drug-testing detection; and 4. To allow disclosure of my drug-testing results only for purposes related to eligibility for participation in NCAA competition.

17 Form 16-3e Page No. 3 I understand that if I sign this statement falsely or erroneously, I violate NCAA legislation on ethical conduct, and will jeopardize my eligibility. Signature of student-athlete Signature of parent (if student-athlete is a minor) Name (please print) of birth Age Home address (street, city, state and ZIP code) Sport(s) What to do with this form: Sign and return it to your director of athletics at the time your intercollegiate squad first reports for practice or before the first date of competition (whichever date occurs first). This form is to be kept on file at the institution for six years. NCAA/05_09_2016/AT:kas

18 Student-Athlete Authorization/Consent for Disclosure of Protected Health Information for NCAA-Related Research Purposes I, hereby authorize Name of Student-Athlete Name of my Institution and its physicians, athletic trainers and health care personnel to disclose my protected health information including, without limitation, any information regarding any injury, illness, treatment or participation related to or affecting my training for and participation in intercollegiate athletics to the National Collegiate Athletic Association (NCAA), and its designated employees, agents and/or contractors. I further authorize the NCAA to disclose, and/or use, such information as provided herein. I understand that my participation and protected health information may be disclosed to, and/or used by, the NCAA, and authorized third parties to receive such information for the purpose of using injury, relevant illness and participation information collected from multiple student-athletes and institutions in a manner that does not identify myself or my school. The information is provided to NCAA committees, athletics conferences and individual schools, and NCAA-approved researchers to evaluate the effectiveness of health and safety rules and policy, and to study other sports medicine questions. Selected de-identified summary (aggregate) data also are made accessible to the general public as a service to further the general understanding of athletic injury patterns and help develop education on student-athlete health topics. I am making this authorization/consent voluntarily to release my health information otherwise protected by federal regulations under either the Health Information Portability and Accountability Act (HIPAA) or the Family Educational Rights and Privacy Act of 1974 (the Buckley Amendment). The NCAA and institution are not requiring this authorization/consent to be signed. I understand that while HIPAA regulations may not apply to NCAA use or disclosure of my injury/illness information, the NCAA is committed to protecting my privacy. I understand that my data will be stored securely within industry standards. This authorization/consent for transfer of protected health information expires 545 days from the date of my signature below, but I have the right to revoke it in writing at any time by sending written notification to the director of athletics at my institution. I understand that a revocation takes effect on its request date and does not affect any action taken prior to that date. Printed name of student-athlete Signature Signature of parent or legal guardian (if student-athlete is a minor) intra.ncaa.org/sites/ama/operationsteam/6.technologyteam/07.complianceforms/ /divisioni/hipaabuckley /lrz_kh_052516