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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 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
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
Student-Athlete Institutional Promotional Authorization
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.
Sign: ________________________ Date: ______________
Form 18-3b Academic Year: 2018-19
NCAA Division II Student-Athlete Statement
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 3.3.4.9 and NCAA Division II Bylaw
14.1.3.
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 317-917-6222 or consult the NCAA website at
www.ncaa.org.
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 3.3.4.9 and Bylaws 14.1.3, 14.1.3.1 and 18.4.1.4.7.
Spring Hill College
NCAA Division II Student-Athlete Statement
Form 18-3b
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 or have reported any violations of 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
2018-19 Drug-Testing Consent Form (Form No. 18-3e).
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) Date of birth Age
Signature of student-athlete Home address (street or P.O. Box)
Date Home city, state, and ZIP code
Sport(s)
NCAA Division II Student-Athlete Statement
Form 18-3b
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 education-
impacting 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 to
NCAA compliance reviews. You will not be identified by name by the NCAA in any such
published or distributed information.
NCAA Division II Student-Athlete Statement
Form 18-3b
Page No. 4
_________
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 Date
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 sports governing
body that has adopted the World Anti-Doping Agency (WADA) code, 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) Date
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 I have never tested positive for a substance banned by the NCAA
and/or a sports governing body that has adopted the WADA code, nor violated a
drug-testing protocol or failed to show for a drug test conducted by the NCAA or a
sports governing body.
____________________________________________________
Name of student-athlete (please print)
_________________________________ _______________
Signature of student-athlete Date
NCAA Division II Student-Athlete Statement
Form 18-3b
Page No. 5
_________
b. Positive drug test.
I have tested positive for a substance banned by the NCAA and/or by a sports
governing body that has adopted the WADA code, or have violated a drug-testing
protocol or failed to show for a drug test conducted by the NCAA or a sports
governing body. If I transfer to another institution, I am also obligated to report this
information to that institution.
Name of student-athlete (please print)
Signature of student-athlete
Date of test Organization conducting test Substance
Are you currently under such a drug-testing suspension? Yes ____ No ____
NCAA Division II Student-Athlete Statement
Form 18-3b
Page No. 6
_________
NCAA/06_08_2018/CNC:na:dks
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) Date
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) Date
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 academic and membership affairs staff at 317-917-6222.
Form 18-3e Academic Year: 2018-19
NCAA Division II Drug-Testing Consent
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 3.3.4.10 and NCAA Division II Bylaw
14.1.4.1.
Purpose:
Effective
date:
To assist in certifying eligibility.
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 3.3.4.10 and NCAA Bylaw 14.1.4.1. 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 31.2.3.1 (Attachment). Examples of drugs under each class
can be found at www.ncaa.org/drugtesting. Note: There is no complete list of banned substances.
Check Drug Free Sport AXIS at 877-202-0769 or www.drugsfreesport.com/axis (Password:
ncaa1, ncaa2, or ncaa3) 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 an "illicit 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 "illicit drug" shall be withheld from competition for 50 percent of a season in all sports
Spring Hill College
NCAA Division II Drug-Testing Consent
Form 18-3e
Page No. 2
_________
(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 an
"illicit drug" shall lose all remaining regular season and postseason eligibility in all sports.
A student-athlete who tests positive a second time for an "illicit 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 an "illicit 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 competitions 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 competitions 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
NCAA Division II Drug-Testing Consent
Form 18-3e
Page No. 3
_________
4. To allow disclosure of my drug-testing results only for purposes related to eligibility for
participation in NCAA competition.
I understand that if I sign this statement falsely or erroneously, I violate NCAA legislation on
ethical conduct and will jeopardize my eligibility.
Date Signature of student-athlete
Date Signature of parent (if student-athlete is a minor)
Name (please print) Date 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/06_05_2018/SH:tas
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 institution. 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 athletics 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 Date
If a student-athlete is under 18 years of age, parent/legal guardian is also required to sign this form.
____________________________________ _____________________________________
Printed Name of Parent/Legal Guardian Signature Date
Spring Hill College
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