If you answered “Yes” to Question 1 or 2 or any portion of Question 3 and 4, please provide a detailed explanation of each such matter including but not limited to the court in which each such matter is pending or was adjudicated, the case number and the date of the filing or disposition.

  1. Have you been disciplined, suspended or placed on probation for any reason at any Collegiate Institution†? If yes, please provide a detailed explanation.
  2. At the time you ceased enrollment at a previous Collegiate Institution†, were you the subject of a pending proceeding of any sort that could have resulted in disciplinary action, suspension, expulsion or probation? If yes, please provide a detailed explanation.
  3. Have you ever provided the information requested in this matter to any other Collegiate Institution†? If yes, please list those institutions.

Answers to these questions, at a minimum, must be provided by each current and prospective student-athlete even when KSU has no independent reason to suspect the current or prospective student-athlete may have engaged in conduct that would trigger KSU's Interim Title IX and Other Sexual Misconduct Policy ("Title IX Policy"). Current and prospective student-athletes shall be notified that failure to disclose any kind of Serious Misconduct may result in disciplinary action, up to and including expulsion from KSU. When KSU has an independent reason to inquire into a current or prospective student-athletes prior conduct, the institution shall conduct a thorough inquiry designed to gather all information needed to assess the situation, including but not limited to a background check and internet search. KSU is expected to ask the student-athlete and others who might possess pertinent information to provide any such information, and where appropriate, to request authorization from such persons to obtain pertinent documents and information from third parties. When a question exists whether the student-athlete has triggered the Title IX policy or engaged in serious misconduct, the KSU Student-Athlete Conduct Advisory Committee shall be notified prior to making the decision to provide aid or allow the student-athlete to practice or compete. All information provided will be kept confidential to the extent authorized by applicable law.

By checking the boxes and signing below, you certify:

  • I have read and understood this form.
  • All my answers are truthful to the best of my knowledge.
  • I give KSU permission to looking into any of the above-disclosed matters.

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Signature of Student-Athlete OR Parent/Guardian

Printed Name of Signatory

(Signature of Parent/Guardian required if Participant is under the age of 18)

Date

† The term ‘Collegiate Institution’ includes but is not limited to any two-year college (e.g., junior college or community college) and any four-year college or university.

1 By reference to The Interim Title IX and Other Sexual Misconduct Policy and other Serious Misconduct is defined as any act of rape, sexual assault, sexual violence, domestic violence, dating violence, stalking, sexual exploitation, sexual harassment, incest, hate crimes, murder, manslaughter or any assault that employs the use of a deadly weapon or causes serious bodily injury. https://www.kysu.edu/student-engagement-and-campus-life/title-ix/TitleIXPolicy.pdf

ONWARD. UPWARD. FORWARD.