PROSPECTIVE STUDENT-ATHLETE (PSA) FORM

Date: ___________________________

 

Name:	______________________________	_____________________________	_______
	Last	First	M.I.

Class Rank: ____________

SAT: __________

ACT: __________

Social Security Number: _____________________	Birthdate: _______________
Street Address: ____________________________	Telephone: ________________
City: _____________________________	State: ______		Zip: ______________

List High School(s) attended beginning with the 9th grade:

	High School Name	City/State
9th	_________________________________	_________________________________
10th	_________________________________	_________________________________
11th	_________________________________	_________________________________
12th	_________________________________	_________________________________

Month and Year of Graduation      ________/________

All prospective freshmen student-athletes enrolling at IUPUI must have initial eligibility certified by the NCAA Clearinghouse. All Junior College transferees who have not graduated and any freshman or sophomore transferee from a 4-year institution who has not completed one full academic year must also be certified by the Clearinghouse. A Clearinghouse form may be obtained from any high school.

Identify any previous college, business school or technical school the applicant may have attended and indicate both dates of enrollment and season of varsity sport participation:

INSTITUTION	CITY/STATE	DATES ATTENDED	VARSITY SPORT(S)

Starting term at IUPUI: __________ Year ________.
(If starting term is in the future, has student applied to IUPUI? ____ Yes ____ No).

IUPUI Sport: ______________________ Coach ____________ Phone: __________

This form should be forwarded to Bret Shambaugh.

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