Spring Hill College Athletics Department STUDENT-ATHLETE PARTICIPATION FORM

Academic Year 2017-18

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 father and mother____________________________________________________________________

OR name of legal guardian(s)_____________________________________________________________________________________

If parents are NOT living together – a) Which parent has legal responsibility for you?________________________________________________________b) Name and address of parent you want mailings sent to (if different from above):

FATHER:__________________________________________ MOTHER: __________________________________________

__________________________________________ __________________________________________

__________________________________________ __________________________________________

Have you ever served in the military? Yes No______

• If yes, please give month/year entered and month/year of discharge___________________

Please indicate your race/ethnicity:

___ Foreign National/Alien ___ Black/African-American ___ Hispanic/Latino

___ White/Caucasian/Non-Hispanic ___ Asian ___ American Indian/Alaskan Native

___ Pacific Islander/Hawaiian ___Two or more Races ___ Unknown

Student-Athlete Financial Aid Information

(1) During this academic year, are you receiving or have arrangements been made for you to receive an athletics scholarship at SHC? 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 2017-2018 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 2017? 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., 20 hrs during season/8 hrs out of season) practice limitations during the 2016-2017 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, 2017 – July 31, 2018 ______________________________________ _____________________________________ ___________________________ 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, 2017 through July 31, 2018

______________________________________ _____________________________________ ___________________________ 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 2017-2018

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 similarservices.

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 17-3b Academic Year: 2017-18

Student-Athlete Statement - NCAA Division II

For: Student-athletes.

Action: Sign and return to your director of athletics or director of

athletics' designee.

Due date: Before your first competition each year.

Required by: NCAA Constitution 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 NCAA Bylaws 14.1.3, 14.1.3.2 and 18.4.1.5.7.

Spring Hill College

Form 17-3b

Page No. 2

_________

Part I: Statement Concerning Eligibility.

You affirm that you have been provided and will read the Summary of NCAA Regulations, or

another outline or summary of NCAA legislation, or the relevant sections of the Division II Manual

and that your director of athletics (or his or her designee) gave you the opportunity to ask questions

about the regulations.

You affirm that you have knowledge of and understand the application of NCAA Division II

bylaws related to your eligibility.

By signing this part of the form you affirm that, to the best of your knowledge, you have not

violated any NCAA regulations.

You affirm that you meet the NCAA regulations for student-athletes regarding eligibility,

recruitment, financial aid, amateur status and involvement in organized gambling.

You affirm that you are aware of the NCAA drug-testing program and that you have signed the

2017-18 Drug-Testing Consent Form (Form No. 17-3e).

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)

Form 17-3b

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.

Form 17-3b

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

Form 17-3b

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 ____

Form 17-3b

Page No. 6

_________

NCAA/04_24_2017/CNC:rf

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 17-3e Academic Year: 2017-18

Drug-Testing Consent - NCAA Division II

For: Student-athletes.

Action: Sign and return to your director of athletics.

Due date: At the time your intercollegiate squad first reports for practice or

the first day of competition or before the Monday of the fourth

week of classes, whichever is earlier.

Required

by:

NCAA Constitution 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

Form 17-3e

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 competition during the time period ending

two calendar years (730 days) from the date of the test.

7. If a student-athlete transfers to a non-NCAA institution while ineligible because of a

positive NCAA drug test, and competes in collegiate competition within the prescribed

penalty at a non-NCAA institution, the student-athlete will be ineligible for all NCAA

regular-season and postseason competition until the student-athlete does not compete in

collegiate competition for the entirety of the prescribed penalty.

Signatures.

By signing below, I consent:

1. To be tested by the NCAA in accordance with NCAA drug-testing policy, which provides

among other things that:

a. I will be notified of selection to be tested;

b. I must appear for NCAA testing or be sanctioned for a positive drug test; and

c. My urine sample collection will be observed by a person of my same gender;

2. To accept the consequences of a positive drug test or a breach of drug testing protocol;

3. To allow my drug-test sample to be used by the NCAA drug-testing laboratories for

research purposes to improve drug-testing detection; and

4. To allow disclosure of my drug-testing results only for purposes related to eligibility for

participation in NCAA competition.

Form 17-3e

Page No. 3

_________

I understand that if I sign this statement falsely or erroneously, I violate NCAA legislation on

ethical conduct and will jeopardize my eligibility.

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/6_5_2017/dks

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

NCAA, and its designated employees, agents and/or contractors. I further authorize the NCAA to

disclose, and/or use, such information as provided herein.

I understand that my participation and protected health information may be disclosed to, and/or used

by, the NCAA and authorized third parties to receive such information for the purpose of using injury,

relevant illness and participation information collected from multiple student-athletes and institutions

in a manner that does not identify myself or my school. The information is provided to NCAA

committees, athletics conferences and individual schools, and NCAA-approved researchers to evaluate

the effectiveness of health and safety rules and policy, and to study other sports medicine questions.

Selected de-identified summary (aggregate) data also are made accessible to the general public as a

service to further the general understanding of athletic injury patterns and help develop education on

student-athlete health topics.

I am making this authorization/consent voluntarily to release my health information otherwise

protected by federal regulations under either the Health Insurance Portability and Accountability Act

of 1996 (HIPAA) or the Family Educational Rights and Privacy Act of 1984 (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 19 years of age, parent/legal guardian is also required to sign this form.

____________________________________ _____________________________________

Printed Name of Parent/Legal Guardian Signature Date

Spring Hill College

Southern Intercollegiate Athletic Conference (SIAC)

Member Institution: Spring Hill College

PROMOTIONAL AUTHORIZATION

In accordance with NCAA Bylaw 12.5.1.1, I, _________________________________ (Print Name), give my permission to authorized representatives of the Southern Intercollegiate Athletic Conference and Member Institutions of the SIAC to use my name, picture, identity, appearance and personal academic (e.g., cumulative GPA, academic major) and athletic (e.g., batting average, points, yards) statistics for institutional and conference promotional activities.

Promotional activities include but are not limited to game promotional activities, ticket sales, press releases, information provided for articles and stories by outside media entities, fundraisers, posters, schedule cards, calendars, institutional charitable or community activities, booster functions, and institutional marketing (e.g., admissions). All monies derived from such conference and institutional promotions are required to be provided directly to the SIAC or Member Institution.

_________________________________________________ __________________ Signature of Student-Athlete Date

_________________________________________________ __________________ Signature of Parent/Guardian (if student-athlete is under 19) Date