Spring Hill College Athletics Department STUDENT-ATHLETE PARTICIPATION FORM Academic Year 2018-19 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 Email Address: (please print clearly!)__________________________________________________________________ Cell Phone: ____________________________________ SHC Address ________________________________________OR_________________________________________________________ Dorm and Room No. Street Apt. No. ___________________________________________________________________________________________________ City State Zip Home Address _____________________________________________________ A Parent’s Cell______________________________ Street Apt. No. ___________________________________________________________________________________________________ City State Zip First and Last name of living parents or legal guardian(s)______________________________________________________________ If parents are NOT living together – a) Which parent has legal responsibility for you?________________________________________________________ b) Contact information of parent you want information provided to (if different from above): Mailing Address _______________________________________________ Cell Phone #__________________________________ Street Apt. No. ___________________________________________________________________________________________________ City State Zip Email Address________________________________________________ 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: ___ International/Foreigner ___ Black/African-American ___ Hispanic/Latino ___ White/Caucasian/Non-Hispanic ___ Asian ___ American Indian/Alaskan Native ___ Pacific Islander/Hawaiian ___Two or more Races ___ Unknown
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Spring Hill College Athletics Department · 2018-07-06 · Spring Hill College Athletics Department . STUDENT-ATHLETE PARTICIPATION FORM . Academic Year 2018-19 . CHECK HERE IF FIRST
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Spring Hill College Athletics Department STUDENT-ATHLETE PARTICIPATION FORM
Academic Year 2018-19
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 ________________________________________OR_________________________________________________________ Dorm and Room No. Street Apt. No.
___________________________________________________________________________________________________ City State Zip
Home Address _____________________________________________________ A Parent’s Cell______________________________ Street Apt. No.
___________________________________________________________________________________________________ City State Zip
First and Last name of living parents or legal guardian(s)______________________________________________________________
If parents are NOT living together – a) Which parent has legal responsibility for you?________________________________________________________b) Contact information of parent you want information provided to (if different from above):
Mailing Address _______________________________________________ Cell Phone #__________________________________ Street Apt. No.
___________________________________________________________________________________________________ City State Zip
___ White/Caucasian/Non-Hispanic ___ Asian ___ American Indian/Alaskan Native
___ Pacific Islander/Hawaiian ___Two or more Races ___ Unknown
Student-Athlete Financial Aid Information
(1) During this academic year, are you receiving or have arrangements been made for you to receive an athletic scholarship at SHC? YES NO (2) Will you be receiving any other financial aid, scholarship or employment earnings, including money or other material benefits? YES NO If YES, 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? YES NO If YES, please name the person/organization providing the items: ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ If YES, describe the equipment, apparel, supplies or prizes: ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ (4) At the present time, will anyone other than you 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? YES NO If YES, name anyone who is receiving such benefits:______________________________________________ If YES, describe such benefits:____________________________________________________________________ If YES, name the source of such benefits:_________________________________________________________
OUTSIDE SCHOLARSHIPS Please give the following information for each outside scholarship you will be receiving during the 2018-2019 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.
Automobile Information
*Do you have the use of a motor vehicle? YES NO
If you answered NO 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? YES NO *If YES, please describe the situation:_________________________________________________________________________ ______________________________________________________________________________________________________________ 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? ____________________________________________________________________________________ Is there an outstanding loan on the automobile? YES NO
*IF YES, who makes the loan payments?_______________________________________________________________
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? YES NO *If YES, please list with whom you share it: 1. __________________________2. _________________________3. _________________________ 4. __________________________ (4) What is your monthly rent and deposit?_________________ What is the length of your lease?____________________ (5) Who is paying your rent? ______________________________
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 YES or NO:
1 Have you ever used your athletics ability to earn salary, benefits, cash?
YES NO
2 Have you ever accepted a promise of pay to be received following completion of your college eligibility?
YES NO
3 Have you ever signed a contract or entered into an oral agreement of any kind in regard to professional athletics?
YES NO
4 Have you ever received pay, financial assistance or consideration from a professional sports organization?
YES NO
5 Have you ever played or practiced with any team with professional athletes?
YES NO
6 Have you ever entered into a professional sports draft?
YES NO
7 Have you ever had a tryout with a professional sports team?
YES NO
8 Have you ever had a physical examination conducted by a professional sports team during the academic year while you still had eligibility remaining?
YES NO
9 Has any SHC coach, staff member or booster ever allowed you to use a vehicle? If YES, please describe:
YES NO
10 Have you ever played in any event where the participants were paid?
YES NO
11 Have you ever received expenses to cover development training, coaching, equipment, apparel, supplies, insurance, travel or accommodations?
YES NO
12 If your answer to question #11 was YES, were the expenses provided by the USOC or the national governing body of the sport?
YES NO
13 Did you participate in outside competition during summer 2018? If YES, what team did you participate on or what race events did you participate in? If YES, who paid your expenses? Did you receive any prizes, awards or cash for participating in these competitions? If YES, please list:
YES YES
NO NO
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?
YES NO
15 Have you ever been paid to serve as an official or referee with a professional sports organization?
YES NO
16 Have you ever permitted the use of your name or picture in advertisements for promotional purposes?
YES NO
17 Have you ever received any pay or other compensation for appearing on TV or radio?
YES NO
18 Have you ever publicly endorsed or promoted products or services without identifying yourself by name or as a member of a SHC team?
YES NO
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? YES NO If YES, 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. YES NO
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.) YES NO
(Returning SA’s) Did SHC coaches exceed daily (i.e., 4 hr per day) or weekly (i.e., 15/20 hrs in season / 8 hrs out of season) practice limitations during the 2017-2018 academic year? YES NO 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 Date
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, 2018 – July 31, 2019 ______________________________________ _____________________________________ ___________________________ Signature of Student-Athlete Printed Name of Student-Athlete Date 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, 2018 – July 31, 2019
______________________________________ _____________________________________ ___________________________ Signature of Student-Athlete Printed Name of Student-Athlete Date _____________________________________________________________________ ___________________________ Signature of Parent/Guardian (if student-athlete is under 19) Date
Spring Hill College Student-Athlete Employment During 2018-2019
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.