Slippery Rock University Athletics - 2010-11 SRU Squad Record and Buckley Amendment Form

2010-11 SRU Squad Record and Buckley Amendment Form

All SRU student-athletes must complete and submit a Squad Record Form and Buckley Amendment Form.

GENERAL INFORMATION
First Name *
Middle Name *
Last Name *
Nickname
Height *
Weight (men only)
Birthdate *
Social Security Number *
Race *	Black White Asian Hispanic American Indian Native Hawaiian Two or more races Other
COLLEGE INFORMATION
SRU major *
Date of Entrance *
Total Credits to Date *
Present Academic Status (Fr., So., Jr., or Sr.) *
Sport(s) Played at SRU *
Position *
Previous years participating in this sport at SRU (Do not include this year) *
Athletic Class *
GPA at conclusion of 2008-09 academic year. PLEASE NOTE: Providing this information is optional. Information gathered here will be used only as part of a nomination process of Academic All-District or Academic All-America honors.
CONTACT INFORMATION
Your E-mail Address *
Parents Names *
Home Address *
Home Telephone *
Cell Phone *
College Address *
TRANSFER INFORMATION
Institution Attended (include city and state)
Number of Semesters
Dates of Attendance (include month and year started and ended)
Sports participated in and number of years
Did you earn any varsity letters at your previous school? If so, how many and in what sports?
HIGH SCHOOL INFORMATION
High School Graduated From *
City and State *
Year of Graduation *
Sports played in high school *
Varsity letters won (Please list and sport and number) *
Highlights of high school career (Example: All-league, all-city, all-county, all-district, all-region, all-state, All-American, all-star games). Please list conference name and district/region/state number and classification.
Were you a member of a championship team? If so, please list sport and championship(s) won.
Academic awards or honors received
Please list your hometown newspaper, radio station and/or television station. Please make sure to designate the city in which the media outlet is located. *
Have any of your relatives graduated from SRU? If so, please list their name and relationship
BUCKLEY AMENDMENT The Buckley Amendment is the common name for the Family Educational Rights and Privacy Act (FERPA) of 1974. This federal law was designed to protect the privacy of a student's educational records, limiting the information that may be disclosed without the student's written permission to "directory information." "Directory information" includes the student's name, addresses (local, permanent and e-mail), telephone number (local and permanent), date and place of birth, major field of study, concentration(s) and minor(s), participation in recognition activities (i.e. athletics), height and weight of members of athletic teams, dates of attendance, degrees and awards received, all educational institutions previously attended, academic awards/scholarships, title of master thesis, number of credits (full-time and part-time) for which a student is registered, pictures of student in university publications, press releases and advertisements, class level and anticipated graduation date. PLEASE NOTE: Students have the right to refuse to permit the release of any of the above information, but that is an issue you must address with the Office of Academic Records, Room 107, Old Main Building.
I agree to allow the Slippery Rock University Sports Information Office to release basic information to media outlets concerning participation status in areas such as medical, eligibility and disciplinary (university/team rules). *	YesNo
In accordance with the Buckley Amendment, I hereby grant permission to the Slippery Rock University Sports Information Office to use information I have provided on the above Squad Record Form during the 2009-10 academic year for the purposes of publicity *	YesNo
In accordance with the Buckley Amendment, I hereby grant permission to the Slippery Rock University Sports Information Office to release my grade point average (GPA) for the purpose of nominating me for and/or publicizing my selection as the recipient of ESPN The Magazine Academic All-District, ESPN The Magazine Academic All-America, PSAC Scholar-Athlete and/or similar student-athlete honors. *	YesNo
Student-Athlete's Full Name (This shall serve as your written permission to release the above mentioned information) *

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