BOSTON COLLEGE ATHLETIC ASSOCIATION

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BOSTON COLLEGE ATHLETICS DEPARTMENT

ELIGIBILITY AND CLEARANCE STATEMENT (2012-2013)

Name __________________________________________ Sport(s) __________________________________________________

Preferred Name __________________________________ Class Year (circle one): Fr. So. Jr. Sr. 5th

Eagle ID ________________________________________ BC e-mail address__________________________________________

Cell phone ______________________________________ Local address ______________________________________________

In case of emergency notify _____________________________________________________________________________________

Relationship ________________________________ Phone number _______________________________

NEWCOMERS ONLY 1. HIGH SCHOOL INFORMATION

Name of high school/prep school ______________________________________________________________________________

Graduation Date: Month _________ Year _________ 3. Location (city, state) _____________________________________

Was the school: PUBLIC or PRIVATE

If private, who paid for your tuition / expenses to go to the above school(s)? _______________________________________

Did you receive a scholarship or grant to attend high school and/or prep school? Yes No

If yes, who provided the scholarship/grant?_________________________________________________________________

If yes, what did it cover? (Please check all that apply.)

Tuition Room/Board $ Provide Amount ________ Other (Explain)___________________________

If yes, was the scholarship/grant directly from the school? _____________________________________________________

If yes, what was the amount of the scholarship/grant? _________________________________________________________

2. How old were you when you initially enrolled full-time in college? Age ________

3. If you were 21 years old or older when you initially enrolled full-time in college, did you compete in ANY organized competition

after you turned 21? Yes No

If “Yes”, please list the following:

Sport __________________________________ Name of team _____________________________________________

Name/location of tournament/competition ________________________________________________________________

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4. After completion of your high school eligibility in high school and before graduation from high school, did you participate in any

all-star contests? Yes No

If Yes: How many all-star competitions did you compete in? _______________________________________________

Name(s) of all-star competition(s) ______________________________________________________________

Location(s) _________________________________________________________________________________

Team name(s) _______________________________________________________________________________

Award(s) received ___________________________________________________________________________

5. History of attendance at other colleges: For each academic year, please list ALL collegiate institutions that you have attended. On

the chart below, indicate whether you were enrolled full-time or part-time at that institution (Full-time = 12 or more semester hours;

Part-time = 11 semester hours or less).

Institution Full-Time/Part-Time Year Practiced Competed Sport(s)

(please circle one) (circle) (circle one, both, or neither)

________________________ FULL PART 2011-2012 Practiced Competed _____________________




ALL STUDENT-ATHLETES

AMATEURISM

6. Have you ever entered into an oral or written contract with a professional athletics organization or a sports agent, or been

represented by a sports agent in your sport? Yes No

If Yes: Sport ____________________________ Name of Team/Sports Agent __________________________________

Approximate Date of Agreement ________________________________________

7. Have you ever received compensation for your athletic abilities in your sport (e.g., money, comparable prize, compensation for

coaching on a fee-for-lesson basis, etc.)? Yes No

If Yes: Sport __________________________________ Approximate date __________________________________________

Amount received ________________________ Additional information ______________________________________

8. Have you ever taken part in any athletic competition for which you were provided compensation (e.g., cash, comparable prize,

merchandise, expense money based on place finish, etc.)? Yes No



9. Have you ever lent your name to any form of commercial advertising (e.g., newspaper, magazine, charity, radio or television

appearance, billboard, personal appearance, etc.)? Please note that this does not include articles about athletic accomplishments.

Yes No



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OUTSIDE COMPETITION

10. In the past 12 months, have you competed on any non-scholastic team(s) while not representing Boston College (e.g., club teams,

non-intramural teams, city league teams, individual events, etc.)? Yes No

If Yes: Sport _________________________________ Name of team ________________________________________

Location ______________________________ Approximate date ______________________________________

Awards received ____________________________________________________________________________

Additional information ________________________________________________________________________

FINANCIAL AID INFORMATION

NCAA regulations require you to report any form of financial assistance (other than aid provided by your parent(s)/legal guardian(s))

and have the aid disbursed through Boston College. Please list any outside aid (aid NOT from BC), such as awards/scholarships

from a national or town organization, your high school, etc. below. A few examples are awards from the National Merit Scholarship

Corporation, the local Rotary Club, your high school graduation, a town sports booster club, etc. You do not need to list loans that

you will be paying back on a regular schedule.

Are you receiving any outside aid? Yes No

If Yes, please list the following information below (for additional awards, please use the back of this page):

Name of award ______________________________________________________________________________

Amount of the award _________________________________________________________________________

Name of awarding agency ____________________________________________________________________

Criteria for receiving award ___________________________________________________________________

Did you have to apply for the award? Yes No

Did you already receive the award? Yes No Will the award be sent directly to Boston College? Yes No

EMPLOYMENT INFORMATION

You must receive prior written approval from the Compliance Office for all employment during the academic year, including work

that is part of the BC work-study program. In addition, student-athletes may only be employed in certain offices by the athletic

department in Conte Forum or the Yawkey Athletics Center. However, student-athletes may be employed in the Flynn

Recreation Complex.

Will you be employed this academic year in a non-work-study position? Yes No Maybe

If Yes, please list the following information below (for additional employment, please use the back of this page):

Business name___________________________________________________________________

Job title ________________________________________________________________________

Location (city/state)_______________________________________________________________

Employer/contact person/contact information__________________________________________

Please see the Compliance Office to fill out paperwork prior to starting your employment during the academic year. In

addition, if any of this employment information changes or you checked off “No/Maybe” and decide later in the year that you would

like to start working, please also see the Compliance Office before you do so.

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INSTITUTIONAL/COMPLIANCE COMMITMENT – STUDENT-ATHLETE CODE OF CONDUCT

I certify that as a participant in the University’s athletics programs, I understand that athletics participation is a privilege and not a right. To enjoy the

privileges of athletics participation, I will adhere to all codes of conduct including, but not limited to, those listed below.

I understand that as a participant in the University’s athletics program, I am expected to behave in a manner that is consistent with the principles of

Boston College and as a respectful member of an intercollegiate team. Inappropriate behavior may result in disciplinary action and removal from the

team.

I understand that in order to participate in intercollegiate athletics, I must be enrolled in a minimum of 12 semester hours of credit each semester. I

also understand that I must satisfactorily complete 6 degree applicable credit hours each term (and 9 degree applicable credit hours for football during

fall semester). I understand that I must meet all other NCAA academic requirements and the requirements appropriate to my academic program as

outlined in the University Catalogue in order to be eligible for participation (see appropriate pages in Student-Athlete Handbook).

I understand that to be eligible in the fifth semester or subsequent semesters of my enrollment, I must designate a specific baccalaureate degree

program (major). Eligibility for all student activities at Boston College, including athletics, is determined by each school.

I understand that under NCAA Bylaw 15, I will be ineligible for intercollegiate athletics if I accept financial aid from anyone other than (a) my

family; (b) the university financial aid office; (c) an awarding agency that provides me with scholarship monies that have nothing to do with my

athletics abilities; (d) employment earnings for which I actually earn the going rate of pay for the locale in which the employment occurs; or (e) bona

fide loans. I also understand that I must report the receipt of all grants and scholarships, and in most instances have those funds disbursed through the

University.

I understand that any employment during the academic year (with the exception of official school vacation periods) that is not part of the Boston

College work-study program must receive prior written approval from the Compliance Office. Failure to receive such prior approval may render me

ineligible for intercollegiate athletics.

I understand that if for any reason the sum of athletic financial aid or other grants or scholarships exceeds the maximum amount allowed under

NCAA legislation, scholastic credits and graduation certificates may be withheld until the excess monies have been repaid.

I understand that accepting gifts, cash, or extra benefits of any nature is strictly prohibited and I will in no way jeopardize the integrity of the

institution, my eligibility, and the team's eligibility by doing so.

I understand that I may not professionalize myself in any manner, including any agreement with an agent to represent me (verbally or in writing),

prior to my eligibility expiring.

I am fully aware that I may not be involved in any gambling activities including, but not limited to: (a) Providing information to individuals involved

in organized gambling activities concerning intercollegiate athletics competition; (b) Soliciting a bet on any intercollegiate team; (c) Accepting a bet

on any team representing the institution; (d) Soliciting or accepting a bet on any intercollegiate competition for any item (e.g. cash, shirt, dinner, etc.)

that has tangible value; or (e) Participating in any gambling activity that involves intercollegiate athletics or professional athletics, through a

bookmaker, a parlay card, the internet or any other method employed by organized gambling.

I certify to the best of my knowledge that I am eligible for athletic participation under the rules and regulations of Boston College, affiliated

conferences and the NCAA. I also understand my responsibility to comply with NCAA, Atlantic Coast Conference, and institutional requirements.

I understand that it is my responsibility to report any violations of NCAA rules, of which I am aware, to my coach and/or a University official. I

attended a rules education meeting conducted by the Boston College Athletics Department and was given the opportunity to ask questions.

I certify that the information that I have shared with University representatives is true and complete to the best of my knowledge and understand that

providing false or misleading information may jeopardize my eligibility for practice, competition, and athletically related aid.

I understand that failure to conduct myself responsibly, as stated and implied by the conditions above, may lead to my dismissal from and

association with the intercollegiate athletics program at Boston College and may also lead to the immediate cancellation of any athletically

related aid. I will represent Boston College and conduct all my activities in a manner that reflects my personal commitment and the moral

and ethical values becoming of a Boston College student-athlete.

Student-Athlete _________________________________________ Sport(s) _________________________ Date ___________________

Signature

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Form 12-3d Academic Year 2012-13

Drug-Testing Consent NCAA Division I

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

Monday of the institution’s fourth week of classes, whichever date

occurs first.

Required by: NCAA Constitution 3.2.4.7 and NCAA Bylaw 14.1.4.

Purpose: To assist in certifying eligibility.

Requirement to sign Drug Testing Consent Form.

Name of your institution: ____Boston College_______________________________________________

You must sign this form to participate (i.e., practice or compete) in intercollegiate athletics per NCAA Constitution

3.2.4.7 and NCAA Bylaw 14.1.4. 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 in relation to any participation by you in any NCAA championship or in any

postseason football game certified by the NCAA for the banned drugs listed in Bylaw 31.2.3 (attached). Additionally, if

you participate in a NCAA Division I sport, you also agree to be tested on a year-round basis.

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 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;

2. A student-athlete who tests positive has an opportunity to appeal the positive drug test;

3. A student-athlete who tests positive a second time for the use of any drug other than a “street drug” shall lose all

remaining regular-season and postseason eligibility in all sports. A combination of two positive tests involving street

drugs (marijuana, THC or heroin), in whatever order, will result in the loss of an additional year of eligibility;

4. 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; and

5. If a student-athlete immediately transfers to a non-NCAA institution while ineligible because of a positive NCAA

drug test, and competes in collegiate competition within the 365 day period 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 a 365 day period.

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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;

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.

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

______________________________________________________________________________

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 the Monday of the institution's fourth week of classes (whichever date occurs first). This

form is to be kept on file at the institution for six years.

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Boston College Athletic Department

POLICY AND PROGRAM FOR DRUG EDUCATION AND TESTING IN INTERCOLLEGIATE

ATHLETICS

2012-2013 CONSENT FORM

I understand that my participation in the Program described herein is required as a condition for my participation in

intercollegiate sports at Boston College. I understand that it is my personal responsibility to remain free of all banned

substances and I will be subject to penalty if I test positive.

I agree to participate in said Program and to be subject to its terms. I accept designated University staff overseeing my

participation in the Program, the obtaining of urine specimens from me, the testing and analysis of such specimens, the

keeping of confidential records and results of such tests, and related activities as set forth in said Program. I agree to

cooperate in furnishing my urine specimens from time to time as requested.

I further agree and consent to the disclosure of said records and results relating to me to those persons and under the

circumstances described in The Program. This consent is given pursuant to all state and federal privacy statutes and is a

waiver of my rights to non-disclosure of such test records and results, to the extent of the disclosures authorized in The

Program. I understand that, in addition to disclosures authorized by The Program, Boston College may be required by law

under certain circumstances to disclose the records and test results relating to me, as in the case, for example, of a lawfully

issued subpoena.

I understand that I may revoke this Consent Form at any time, so far as any participation in subsequent tests is concerned.

However, if I revoke this Consent Form or refuse to participate in the Program, I understand that I may not be allowed to

participate in intercollegiate athletics at Boston College and any athletic scholarship that I hold may not be renewed for

the next year.

Signature Date

Name (printed) Sport

-------------------------------------------------------------------------------------------------------------------

_____ Check here if under 18 and print parent or guardian’s name and address below.

Parent/Guardian’s First and Last Name_____________________________________________

Address______________________________________________________________________

Signature of Parent or Guardian Date

(if student-athlete is a minor)

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Form 12-3a

Academic Year 2012-13

Student-Athlete Statement – NCAA Division I

Student-Athlete: ____________________________________________________________

(Please print name)

Name of your institution: _____Boston College__________________________________

This form has seven parts: 1) a statement concerning eligibility; 2) a Buckley Amendment consent; 3) an affirmation of status as an

amateur athlete; 4) a statement concerning the promotion of NCAA championships and other NCAA events; 5) results of drug tests; 6)

previous involvement in NCAA rules violation(s); and 7) an affirmation of valid and accurate information provided to the NCAA

Eligibility Center and admissions office, including ACT or SAT scores, high school attendance, completion of coursework and high

school grades. If you are an incoming freshman, you must complete and sign Parts I, II, III, IV, V and VII to participate in

intercollegiate competition. If you are an incoming transfer student or a continuing student, you must complete and sign Parts I, II, III,

IV, V and VI to participate in intercollegiate competition. Before you sign this form, you should read the Summary of NCAA

Regulations, or another outline or summary of NCAA legislation, provided by your director of athletics or his or her designee or read

the bylaws of the NCAA Division I Manual that deal with your eligibility. You are responsible for knowing and understanding the

application of all NCAA Division I bylaws related to your eligibility. If you have any questions, you should discuss them with your

director of athletics or your institution’s compliance officer, or you may contact the NCAA at 317/917-6222. The conditions that you

must meet to be eligible and the requirement that you sign this form are indicated in the following bylaws of the Division I Manual:

NCAA Bylaws 10, 12, 13, 14, 15, 16, 18.4 and 31.2.3.


Part I: Statement Concerning Eligibility.

By signing this part of the form, you affirm that, to the best of your knowledge, you are eligible to compete in intercollegiate

competition. You affirm that your institution has provided you a copy of the Summary of NCAA Regulations, or another outline or

summary of NCAA legislation, or the relevant sections of the Division I Manual and that your director of athletics (or his or her

designee) gave you the opportunity to ask questions about them. You affirm that you have knowledge of and understand the

application of NCAA Division I bylaws related to your eligibility. You affirm that you meet the NCAA regulations for student-

athletes regarding eligibility, recruitment, financial aid, amateur status and involvement in gambling activities. You affirm that you

are aware of the NCAA drug-testing program and that you have signed the current NCAA Drug Testing Consent Form. You affirm

that all information provided to the NCAA, the Eligibility Center and the institution’s admissions office is accurate and valid,

including ACT or SAT scores, high school attendance, completion of coursework and high school grades, as well as your amateur

status. You affirm that you have reported to the director of athletics or his or her designee 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 on ethical conduct and you will further jeopardize your eligibility.

Name (please print) Date of birth Age

Signature of student-athlete Date Sport(s)

Permanent Home Address (street or P.O. Box) Home city State ZIP code

For: Student-athletes.

Action: Sign and return to your director of athletics.

Due date: Before you first compete each year.

Required by: NCAA Constitution 3.2.4.6 and NCAA Bylaws 14.1.3.1 and 30.12.

Purpose: To assist in certifying eligibility.

Effective Date: This NCAA Division I statement/consent form shall be in effect from the date this document is

signed and shall remain in effect until a subsequent Division I Student-Athlete Statement/Drug-

Testing Consent form is executed.

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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,

except as permitted in the Drug-Testing Consent form, 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 junior college or any 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. Your social security number and/or student identification number;

8. Race and gender identification;

9. Diagnosis of any education-impact disabilities;

10. Accommodations provided or approved and other information related to any education-impact disabilities in all secondary and

postsecondary schools;

11. Records concerning your financial aid; and

12. 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 (e.g. Elite 89), 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

and athletics certification. You will not be identified by name by the NCAA in any such published or distributed information. This

consent shall remain in effect as long as any issues regarding the purposes listed above exist.

You also agree that information regarding any infractions matter in which you may be involved may be published or distributed to

third parties as required by NCAA policies, bylaws or procedures.

Date Signature of Student-Athlete


Part III: Promotion of NCAA Championships, Events, Activities or Programs.

You authorize the NCAA [or a third party acting on behalf of the NCAA (e.g., host institution, conference, local organizing

committee)] to use your name or picture in accordance with Bylaw 12.5.1.1, including to promote NCAA championships or other

NCAA events, activities or programs.

Name (please print)

Signature of student-athlete Date

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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 you signed a Division I 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 amateur status to the NCAA, the Eligibility Center and the institution’s athletics department, including administrative

personnel and the coaching staff.

Name (please print) Date

Signature of student-athlete


Part V: 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 national or international sports governing

body; violate their drug-testing protocol; or fail to show for their drug test, at any time after I sign this statement, I acknowledge

I must report the results to my director of athletics.


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 by a non-NCAA national or international

sports governing body; or violated their drug-testing protocol; or failed to show for their drug test.

Name (please print) Signature of student-athlete Date

B. Positive drug test.

I have tested positive for a substance banned by the NCAA and/or by a non-NCAA national or international sports governing

body; or violated their drug-testing protocol; or failed to show for their drug test. Should I subsequently transfer, I am obligated

to report this to the transferring institution.

Name (please print) Signature of student-athlete Date

Date of test Organization conducting test Substance

Are you currently under such a drug-testing suspension? Yes No

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INCOMING TRANSFERS ONLY

Part VI: Incoming Transfers – Previous Involvement in NCAA Rules Violation(s).

Have you previously attended a four-year NCAA Divisions I, II or III institution?

Yes No

If yes, what is the name(s) of the institution(s)?

Are you aware of any NCAA violations you were involved in while previously attending an NCAA institution?

Yes No

If yes, did this violation result in your being withheld from competition while attending your previous institution?

Yes No

If you answered yes to either of the above questions, please provide an explanation.

INCOMING FRESHMEN ONLY

Part VII: 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 will immediately notify the director of

athletics of your institution. You affirm that all information provided to the NCAA, the Eligibility Center and institution’s admissions

office is valid and accurate, including high school attendance, completion of coursework and high school grades. You affirm that you

did not fraudulently earn your qualifying ACT or SAT score by having someone else take the test for you, copying answers from

another person taking the test, etc.


Signature of student-athlete

\\documentcenter.ncaa.org/DavWWWRoot\msaa\ama\Compliance\Compliance Forms\2011-12\DI_JK:jh_06282011

What to do with this form: Sign and return it to your director of athletics or his or her

designee before you first compete. 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

your institution’s NCAA compliance staff, or you may contact the NCAA at 317/917-

6222.

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BOSTON COLLEGE ATHLETICS DEPARTMENT

INFORMED RISK STATEMENT

Any form of athletic participation involves some risk of injury. Participation in a varsity sport includes

your acceptance of this risk of injury. In order to minimize this risk, as a participant, you must be aware

of and abide by certain procedures, safety rules, and guidelines. Sound conditioning and training

programs are designed to help in the prevention of injury; rehabilitation programs are designed to enable

recovery and return to participation. Your responsibility to these programs is as important as your

responsibility to learning skills, techniques, and strategies in your sport.

Any improper use or abuse of equipment could result in serious injury to you, your teammates and your

opponents. For example, helmets, sticks, bats, clubs, and other equipment may not be used to butt, ram,

or spear an opposing player. Not only is such use in violation of the sport rules, but serious head and

neck injuries, paralysis and even death can result with equipment misuse.

No equipment can prevent all injuries that you might receive while participating in your sport, however,

used in the proper manner, your equipment helps to minimize the risk of injury. Any adjustments to

your equipment should be reviewed with the appropriate equipment manager and/or Sports Medicine

staff member.

All injuries and illnesses should be reported to the Sports Medicine staff or to team physicians as soon as

they become evident to you. Furthermore, it is your responsibility to seek treatment from the medical

staff and to appear for treatment as requested by the medical staff.

In consideration of the opportunity to participate in intercollegiate sports at Boston College during my

entire period of eligibility, I hereby certify that I have read and understand the above statement. I have

had an opportunity to ask for explanation or clarification of any portion, and I agree to observe these and

other related rules and practices that may be employed to minimize my risk of serious injury while

pursuing the benefits of this program.

_____________________________________________________ __________________

Name (print) Date

_____________________________________________________ __________________

Signature Sport(s)

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Institutional, Charitable, Educational, or Nonprofit Promotions Individual Release Statement

Student-Athlete’s Name:

Sport(s):

In accordance with NCAA Bylaw 12.5.1.1, Institutional, Charitable, Educational, or Nonprofit Promotions, a

member institution or recognized entity thereof (e.g., fraternity, sorority, or student government organization),

a member conference, or a non-institutional charitable, educational, or nonprofit agency may use a student-

athlete’s name, picture, or appearance to support its charitable or educational activities or to support activities

considered incidental to the student-athlete’s participation in intercollegiate athletics, provided the following

conditions are met:

The student-athlete receives written approval to participate from the director of athletics (or his or her

designee who may not be a coaching staff member), subject to the limitations on participants in such

activities as set forth in Bylaw 17;

The specific activity or project in which the student-athlete participates does not involve co-sponsorship,

advertisement, or promotion by a commercial agency other than through the reproduction of the

sponsoring company’s officially registered regular trademark or logo on printed materials such as pictures,

posters, or calendars. The company’s emblem, name, address, and telephone number may be included

with the trademark or logo. Personal names, messages, and slogans (other than an officially registered

trademark) are prohibited;

The name or picture of a student-athlete with remaining eligibility may not appear on an institution’s

printed promotional item (e.g., poster, calendar) that includes a reproduction of a product with which a

commercial entity is associated if the commercial entity’s officially registered regular trademark or logo

also appears on the item;

The student-athlete does not miss class;

All moneys derived from the activity or project go directly to the member institution, member conference,

or the charitable, educational, or nonprofit agency;

The student-athlete may accept legitimate and normal expenses from the member institution, member

conference, or the charitable, educational, or nonprofit agency related to participation in such activity;

The student-athlete’s name, picture, or appearance is not utilized to promote the commercial ventures of

any nonprofit agency;

Any commercial items with names or pictures of student-athletes (other than highlight films or media

guides per 12.5.1.8) may be sold only at the member institution at which the student-athlete is enrolled,

institutionally controlled (owned and operated) outlets, or outlets controlled by the charitable or

educational organization (e.g., location of the educational or charitable organization, site of charitable

event during the event); and

The student-athlete and an authorized representative of the charitable, educational, or nonprofit agency

sign a release statement ensuring that the student-athlete’s name, image, or appearance is used in a manner

consistent with the requirements of this section.

As a student-athlete at Boston College, I hereby give my permission to the Boston College Athletics

Department and other charitable, educational or non-profit agencies authorized by the Boston College

Athletics Department to use my name or picture on promotional materials and my appearance at

promotional activities, so long as my name, image or appearance is used in a manner consistent with the

requirements of NCAA Bylaw 12.5.1.1 as set forth above.

Student-Athlete’s Signature Date

BC Compliance Office 7/08

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BOSTON COLLEGE

Automobile Information Form

Name: ______________________________________ Eagle ID: ___________________

Sport: _______________________________________

Do you own or have access to a vehicle (on- or off-campus)? YES NO

If yes:

1. Have you purchased a BC parking permit? YES NO

2. Auto description

A. Year: Color:

Make: Model:

B. License plate number: State:

C. Name of title holder:

D. Relationship of title holder to you:

3. Purchase/financing information

A. Date of purchase (month/year):

B. Car paid in full? YES NO

Person responsible for loan:

C. Who (if anyone) helped you pick this car:

D. How did you purchase this car (e.g., dealer, private sale):

E. Location of purchase (city, state):

F. Who is paying for the insurance for this car:

I certify that the above information is complete and accurate to the best of my knowledge. If the above

information changes, I will notify the Compliance Office immediately.

Signature of Student-Athlete Date

15

BOSTON COLLEGE

Summer 2012 Employment Form

Name: ______________________________________ Eagle ID: ___________________

Sport: _______________________________________

Did you have a summer job? YES NO

If yes:

Employer’s name:

Employer’s address (city, state):

Employer’s phone number:

Employer’s e-mail:

When did you begin working for this employer:

When did you stop working for this employer:

How many days per week did you work:

How many hours per day did you work:

Salary (hourly rate):

Total summer earnings:

Duties performed:

Who was your supervisor:

How did you obtain the job:

I certify that the above information is complete and accurate to the best of my knowledge.

Signature of Student-Athlete Date

16

Student-Athlete Authorization/Consent for

Disclosure of Protected Health Information

for NCAA-Related Research Purposes

I, hereby authorize Boston College

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 purposes 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 Date

17

LEARNING RESOURCES FOR STUDENT-ATHLETES

ACADEMIC PROGRESS MONITORING

PERMISSION FORM

The Office of Learning Resources for Student-Athletes monitors the academic progress of all Boston

College student-athletes. Information learned through communication with the faculty is shared with the

student-athlete and, in most cases, with the student-athlete’s coach. By signing the form below, you are

granting your permission for this office to contact your instructors in regard to your academic progress.

I, grant my permission for the Office of Learning Resources for

Print student-athlete name

Student-Athletes to contact my instructors concerning my academic progress. I understand that this

information will be shared with me, my coach(es), deans and other Boston College affiliated people who

have an interest in supporting my success in the classroom.

Signature Sport(s) Date

400 Yawkey Athletics Center, 140 Commonwealth Avenue, Chestnut Hill, Massachusetts 02467

TEL: 617-552-8533 FAX: 617-552-0822

18

BOSTON COLLEGE SPORTS MEDICINE ANNUAL HEALTH QUESTIONNAIRE

NAME: SPORT:

EAGLE NUMBER: YEAR OF BC GRADUATION:

1. Have you suffered a major injury since your last season? IF “YES” EXPLAIN Yes No

2. Have you been admitted into a hospital since your last season? IF “YES” EXPLAIN Yes No

3. Have you suffered a head injury/concussion in the last 12 months? IF “YES” EXPLAIN Yes No

4. Are you missing a paired organ (kidney, eye, etc.)? IF “YES” EXPLAIN Yes No

5. Have you ever suffered chest pain, dizziness or fainted while exercising? IF “YES” EXPLAIN Yes No

6. Do you require medication on a daily or episodic routine? IF “YES” EXPLAIN Yes No

(Example: insulin, asthma medication)

7. Is ANY doctor presently treating your for ANY disorder? IF “YES” EXPLAIN Yes No

8. Are you allergic to any foods, medications or insects? IF “YES” EXPLAIN Yes No

9. Are you taking any vitamins, minerals or supplements? IF “YES” EXPLAIN Yes No

10. Are there any food groups you choose not to eat (meat, dairy, etc.)? IF “YES” EXPLAIN Yes No

11. Are you suffering from any injury/disorder that will prevent you from

practicing/conditioning/competing with the team right away? IF “YES” EXPLAIN Yes No

12. Do you know of or believe there is any health reason why you should

not participate in intercollegiate athletics at Boston College? IF “YES” EXPLAIN Yes No

THE UNDERSIGNED ATHLETE:

1. Understands that he/she must report ALL injuries and illness to a Sports Medicine Clinician as soon as

possible. This also includes any injuries that were not a result of athletic participation.

2. Understands that he/she must refrain from practice or play during medical treatment until he/she is

discharged and given permission from a Boston College Sports Medicine Clinician to resume participation.

3. Certifies that the answers to the questions above are correct and true.

4. Understands that his/her having passed the physical examination does not necessarily mean that he/she is

physically qualified to engage in athletics, but only that the examiner did not find a medical reason to

disqualify him/her.

SIGNED DATE:

Documents

BOSTON COLLEGE ATHLETIC ASSOCIATION