Full Name:
Social Security Number:
Date of Birth:
Age Upon Enrollment:
Sport:
High School: [name, city, state]
High School Graduation Date:
Have you attended other high schools?
List any other High Schools you attended (and years attended): [school, city, state, semester, years]
Date you entered any college for the first time:
Date enrolled at UR:
Have you ever signed a National Letter of Intent and/or application for athletics related grant-in-aid at the University of Richmond or any other institution? Yes or No. If yes, list school and signing date:
Are you receiving a scholarship FROM ANY SOURCE? Yes or No. If yes, explain in detail:
Are you the recipient of a loan from the University of Richmond? Yes or No. If yes, explain in detail:
Were you athletically recruited by a member of the University of Richmond Department of Athletics? Yes or No. If yes, name of person who recruited you:
"Time Lapse Statement": If you have not continuously attended college as a "full-time student" each semester since your graduation from high school, please describe your activities during the period(s) you were not in school (i.e., work, military service, church mission, illness, etc.) and the exact time period (months and years):
Describe any participation in organized athletics competition during this period:
Have you ever registered at another college and dropped out prior to completion of semester or quarter? Y / N.
List names of all junior colleges, colleges and universities attended:
Were you in good academic standing when you left the college(s) you previously attended? Yes or No.
Were you on probation? Yes or No .
Do you have an associate degree from any of these schools? Yes or No If yes, what college:
: Have you ever practiced with a team and/or participated in organized intercollegiate athletics competition at any junior college, college or university? Yes or No. If yes, complete below:
Have you ever been declared ineligible to participate in intercollegiate athletics? Yes or No. If yes, explain:
I certify that my answers are complete and correct. I understand that any false or incomplete statement in this historical report may make me ineligible for intercollegiate athletics competition and/or any athletically related financial aid at the University of Richmond. If any of the information that I have supplied on this report changes during the year, I will notify the Compliance Coordinator as soon as possible.
Student-Athlete's Signature: & Date:
Certified by the NCAA Initial Eligibility Clearinghouse:
Signed: Kristen A. Ball, Assistant Director of Athletics
&
Date
Institutional NCAA Compliance Coordinator