TITLE IX & SERIOUS MISCONDUCT STUDENT-ATHLETE CONSENT FORM

As a member of the National Collegiate Athletic Association (“NCAA”), Kentucky State University (“KSU”) adheres to the NCAA Board of Governors’ Policy on Campus Sexual Violence as revised on or about April 27, 2021, and gathers certain disciplinary and criminal history about incoming and transfer potential student athletes from their former institutions. Prospective student athletes who wish to participate in NCAA intercollegiate athletics must comply with this procedure.

INSTRUCTIONS:

• Each incoming or transfer prospective student athlete will fill out the top portion of this form.
• A prospective student athlete must fill out a separate form for each K-12 and post-secondary institution they have attended in the past five (5) years.
• Kentucky State University will then send this form to the identified institutions.

TO BE COMPLETED BY THE INCOMING OR TRANSFER PROSPECTIVE STUDENTATHLETE:

FIRST NAME: ___ LAST NAME: ___

DATE OF BIRTH: ___

2023

AUTHORIZATION: I authorize ___ (former institution) to release disciplinary

and/or criminal information from my educational records to Kentucky State University, including records related to the crimes and incidents addressed in the NCAA Policy on Campus Sexual Violence.

STUDENT SIGNATURE: ___

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

DATE:

1/2

TO BE COMPLETED BY FORMER INSTITUTIONS THE STUDENT ATTENDED IN PAST FIVE (5) YEARS:

NOTE: This section must be completed by a school/college/university official with access to student's disciplinary records. INSTITUTION NAME:

INSTITUTION OFFICIAL'S NAME AND TITLE: ___

EMAIL: ___

PHONE: ___