Hold Harmless Agreement
WIAC Player Eligibility Statement/Hold Harmless Agreement SECTION 1 ☐ Yes ☐ No
TRANSFER RECORD: Have you attended another institution, other than for summer school or interim terms?
*If you checked yes, list the school(s) below and include all full time semesters attended as these institutions in the record of full time attendance in section 2. SCHOOL: ________________________
DATES:__________________ to ____________________ Month
SCHOOL: ________________________
SECTION 2
Month
Year
DATES:__________________ to ____________________ Month
☐ Yes ☐ No
Year Year
Month
Year
Have you ever been granted a medical hardship waiver by any intercollegiate athletics association or conference? If “Yes” List sport(s) involved _______________________ Year ____________________________ List who granted request: _________________________________ TERMS OF ATTENDANCE AT ALL INSTITUTIONS:
This listing must include ALL institutions of higher education in which 12 or more credits are attempted (excluding summer school). List each term of attendance separately by semester or quarter (e.g. Fall 2017). Institution
Date of Term
1. UWSP 2. 3. 4. 5.
Fall 2017
Institution
Date of Term
6. 7. 8. 9. 10.
*Total terms of attendance including THIS term_________
High school graduation year:_____________
SECTION 3
CREDITS CARRIED THIS TERM (Must be at least 12): *Second term student, (i.e., freshman) must have passed 9 credit hours prior to his/her second term of attendance.
SECTION 4
MILITARY SERVICE:
☐ YES
☐ NO
Length of Service:
Discharge Date: ___________
SECTION 5
PARTICIPATION: Did you participate in intercollegiate athletics or club sports at any previous or current institution? Practice Compete
☐Yes ☐ No ☐ Yes ☐ No
If you checked “Yes” for either, list below any season(s) of participation in intercollegiate sports:
List below any season(s) of participation in intercollegiate sports:
Name of Institution/State
Sport
Academic Year
Practiced?
*Competed?
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
* Seasons of Competition: Representing an institution against outside competition constitutes a season of competition.
To the best of my knowledge, this is a complete and accurate report of my participation in college athletics. I have read the NCAA Eligibility Regulations and I believe I am eligible under NCAA and WIAC rules. I understand withholding information or providing false information, particularly concerning previous institutional identification and/or competition, will render me ineligible for competition in athletics within the WIAC. Student-Athlete Name (Please Print)
Student-Athlete Signature --Over--
Date
WIAC Hold Harmless Agreement A student who participates in intercollegiate athletics assumes certain inherent risk of injury arising out of his/her participation. The WIAC and the Board of Regents of the University of Wisconsin System do not provide medical or disability insurance covering such injuries and the undersigned is hereby encouraged to secure adequate insurance protection. The undersigned hereby releases the UW-Stevens Point and the member institutions of the WIAC, the Board of Regents of the University of Wisconsin System, their officers, employees and agents from any and all liabilities, demands, and causes of action whatsoever in any way growing out of or resulting from the undersigned student’s participation in any intercollegiate sport. If the undersigned is married or a minor, then the signature of the spouse, parent, or guardian appearing in the space indicated below signifies acceptance by said spouse, parent or guardian that the terms and conditions hereof shall be binding upon them and shall constitute a release by them of any and all claims, demands and causes of action whatsoever which they or any of them may have against the Conference or this institution, its officers, agents or employees as a result of the undersigned student’s participation in the activities described. Date: ____________________
Age:
_____________________________
________________________________
Student-Athlete Name (Please Print)
Student-Athlete Signature
______________________________
__________________________________
Parent Signature (if student-athlete is a minor)
Spouse Signature (if applicable)
NOTE: This form must be filed with the Director of Athletics prior to the student-athlete’s first practice.
Constitution\appendices
TRANSFER RECORD: Have you attended another institution, other than for summer school or interim terms?
*If you checked yes, list the school(s) below and include all full time semesters attended as these institutions in the record of full time attendance in section 2. SCHOOL: ________________________
DATES:__________________ to ____________________ Month
SCHOOL: ________________________
SECTION 2
Month
Year
DATES:__________________ to ____________________ Month
☐ Yes ☐ No
Year Year
Month
Year
Have you ever been granted a medical hardship waiver by any intercollegiate athletics association or conference? If “Yes” List sport(s) involved _______________________ Year ____________________________ List who granted request: _________________________________ TERMS OF ATTENDANCE AT ALL INSTITUTIONS:
This listing must include ALL institutions of higher education in which 12 or more credits are attempted (excluding summer school). List each term of attendance separately by semester or quarter (e.g. Fall 2017). Institution
Date of Term
1. UWSP 2. 3. 4. 5.
Fall 2017
Institution
Date of Term
6. 7. 8. 9. 10.
*Total terms of attendance including THIS term_________
High school graduation year:_____________
SECTION 3
CREDITS CARRIED THIS TERM (Must be at least 12): *Second term student, (i.e., freshman) must have passed 9 credit hours prior to his/her second term of attendance.
SECTION 4
MILITARY SERVICE:
☐ YES
☐ NO
Length of Service:
Discharge Date: ___________
SECTION 5
PARTICIPATION: Did you participate in intercollegiate athletics or club sports at any previous or current institution? Practice Compete
☐Yes ☐ No ☐ Yes ☐ No
If you checked “Yes” for either, list below any season(s) of participation in intercollegiate sports:
List below any season(s) of participation in intercollegiate sports:
Name of Institution/State
Sport
Academic Year
Practiced?
*Competed?
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
* Seasons of Competition: Representing an institution against outside competition constitutes a season of competition.
To the best of my knowledge, this is a complete and accurate report of my participation in college athletics. I have read the NCAA Eligibility Regulations and I believe I am eligible under NCAA and WIAC rules. I understand withholding information or providing false information, particularly concerning previous institutional identification and/or competition, will render me ineligible for competition in athletics within the WIAC. Student-Athlete Name (Please Print)
Student-Athlete Signature --Over--
Date
WIAC Hold Harmless Agreement A student who participates in intercollegiate athletics assumes certain inherent risk of injury arising out of his/her participation. The WIAC and the Board of Regents of the University of Wisconsin System do not provide medical or disability insurance covering such injuries and the undersigned is hereby encouraged to secure adequate insurance protection. The undersigned hereby releases the UW-Stevens Point and the member institutions of the WIAC, the Board of Regents of the University of Wisconsin System, their officers, employees and agents from any and all liabilities, demands, and causes of action whatsoever in any way growing out of or resulting from the undersigned student’s participation in any intercollegiate sport. If the undersigned is married or a minor, then the signature of the spouse, parent, or guardian appearing in the space indicated below signifies acceptance by said spouse, parent or guardian that the terms and conditions hereof shall be binding upon them and shall constitute a release by them of any and all claims, demands and causes of action whatsoever which they or any of them may have against the Conference or this institution, its officers, agents or employees as a result of the undersigned student’s participation in the activities described. Date: ____________________
Age:
_____________________________
________________________________
Student-Athlete Name (Please Print)
Student-Athlete Signature
______________________________
__________________________________
Parent Signature (if student-athlete is a minor)
Spouse Signature (if applicable)
NOTE: This form must be filed with the Director of Athletics prior to the student-athlete’s first practice.
Constitution\appendices
