UNCG SPARTAN G'S 2017 FALL TRYOUTS INFORMATION PACKET. We discover and develop champions in life. -The Spartan Way

UNCG SPARTAN G'S 2017 FALL TRYOUTS INFORMATION PACKET We discover and develop champions in life. -The Spartan Way

2017 UNCG Dance Team Fall Tryouts Fall tryouts will be held Saturday, Sept. 9th Tryout Fee: $20/person Times and locations are as follows: Saturday, Sept. 9, 2017 Time: 9 am - 2 pm Location: Kaplan Center - Gyms 1 and 2 - Room 131 Please arrive by 8:30 am The Leonard J. Kaplan Center for Wellness is the new student recreation center that opened in Fall of 2016. The Kaplan Center is located off of Gate City Blvd. All Tryout Sessions for the UNCG Dance Team are closed, without exception. Video Tryout Submission Submission of a tryout video will be accepted. However, video submissions must be submitted PRIOR to the date of the tryouts and must include all of the following: 1. Eight 8-counts of Pom work (cadences/sidelines/fight song) 2. Any Extensions you can do (arabesque, tilt, needle, etc) 3. Double Pirouette 4. Triple Pirouette 5. Fouette turns or Turns in Second (at least 4 into a double pirouette) 6. Splits (right, left, center) 7. Leaps/Jete's (right, left, center) 8. Calypso 9. Turning disc 10. Channe turns 11. Pique turns 12. High kicks (R/L in front, R/L to the side, arabesque back) 13. Freestyle (Eight 8-counts each of jazz and hip-hop choreography) 14. Any special tricks/tumbling you can do (arial, kip-up, headspring, freeze, etc-- this is the only thing NOT mandatory for the video audition) All questions regarding the UNCG Dance Team tryouts may be directed in writing to the head coach, Megan Cunningham at mdcunningham90@gmail.com. We discover and develop champions in life. -The Spartan Way

General Tryout Information All tryout participants must be: Current, full-time UNCG students (enrolled in a minimum of 12 credit hours) College transfers, or incoming freshman with an acceptance letter. All tryout participants must have a minimum of a 2.3 semester GPA at the time of tryouts. Tryout Attire You must present a clean cut image to be selected as a Spartan G's dancer. Body piercings, tattoos, extreme hairstyles/color are not acceptable at tryouts or in uniform if selected as a team member. Remove all piercings and cover all tattoos prior to arrival at tryouts. Expected attire for tryouts is as follows: Saturday: MUST WEAR SPORTS BRA OR CROP TOP DURING TRYOUTS. All uniforms are sports bra or crop tops so we want all team members to be comfortable wearing these. *Be creative. Rhinestones, costume accessories, etc. Stand out in the crowd!* Dark colored jazz pants or boy shorts Dance shoes "Game Day" makeup Hair down and out of face Shoes must be worn at all times. ("Foot undies" or sandal soles may be worn) We discover and develop champions in life. -The Spartan Way

Greensboro, NC 27402 Fax Number: 336.334.4063 CHECKLIST OF REQUIREMENTS: Tryout Registration Fee: $20, check made payable to UNCG Athletics UNCG Dance Team Tryout Application (Appendix A) All questions on the application must be completed before the application will be processed. Headshot (both listed below) Please submit a photo headshot of yourself and submit along with the other required paperwork. AND Photo copy of UNCG Student ID, if you are a current student Proof of full-time enrollment at UNCG Documentation must be provided via a print-out from UNCGenie that must contain participant s name and current GPA (Appendix B) Copy of 2017 Fall Class Schedule (Appendix C) Students are considered full-time only if they are enrolled in a minimum of 12 credit hours Acceptance letter to UNCG, if an incoming freshman or transfer student Copy of current physical (conducted within the past 6 months) (Appendix D) **(Must be signed by a physician) Health Insurance Information Form (Appendix E) A copy of the front and back of the participants insurance card must accompany this form Consent to Disclose Protected Health Information Form (Appendix F) This form will only be kept on file should the participant be selected as a member of the squad This form requires the signature of a parent or legal guardian, regardless of participant s age ICA Agreement & Release Form (Indemnity Form) (Appendix G) Participants must have a parent or legal guardian s signature This form requires the signature of a parent or legal guardian, regardless of participant s age Insurance Information & Injury Release Forms (Appendix H & I) General Tryout Information continued Tryout Paperwork Requirements All tryout participants must submit the following paperwork and bring their $20 tryout fee (checks made payable to UNCG Athletics) no later than Tuesday, Sept. 5th at 5 pm NO EXCEPTIONS! The Tryout Application and the paperwork included in the UNCG Dance Team Tryout Packet must be submitted directly to the UNCG Dance Team Staff Advisor using one of the methods listed below. All tryout participants are encouraged to submit all paperwork as soon as possible so any issues that may arise can be addressed prior to the final deadline.. By Mail: UNCG Athletics c/o Dacia Ijames 1408 Walker Ave, 101C Coleman Bldg Appendix H requires the signature of a parent or legal guardian, regardless of participant s age. Appendix I only requires a signature of a parent or legal guardian if participant is less than 18 years of age. Sickle Cell Screening Results (Appendix J) **Returning members DO NOT have to complete this requirement. Prospective new members only! Lab Results AND Appendix J must be submitted before tryouts. No exceptions. Please give 24 to 48 hours to receive your lab results. By Fax: To: Dacia Ijames Re: UNCG Dance Tryouts By Drop-off: Room 101C, Coleman Building Attn: Dacia Ijames Appendix J requires the signature of a parent or legal guardian, regardless of participant s age. We discover and develop champions in life. -The Spartan Way

General Tryout Information continued Candidates will be judged on, but are not limited to: 1. Eight 8-counts of Pom work (cadences/sidelines/fight song) 2. Any Extensions you can do (arabesque, tilt, needle, etc) 3. Double Pirouette 4. Triple Pirouette 5. Fouette turns or Turns in Second (at least 4 into a double pirouette) 6. Splits (right, left, center) 7. Leaps/Jete's (right, left, center) 8. Calypso 9. Turning disc 10. Channe turns 11. Pique turns 12. High kicks (R/L in front, R/L to the side, arabesque back) 13. Freestyle (Eight 8-counts each of jazz and hip-hop choreography) 14. Any special tricks/tumbling you can do (arial, kip-up, headspring, freeze, etc-- this is the only thing NOT mandatory for the video audition) Do not assume that a weakness or lack of skill in any one area will automatically disqualify you as a team member. Display an eager and positive attitude at all times. Candidates will tryout in groups of three and will be assigned by the coaching staff on Sunday. The coaching staff will make all final decisions on team member selection. Any candidate that has questions after the team selections are announced may e-mail the UNCG Dance Team coach at mdcunningham90@gmail.com any time AFTER the weekend. Outbursts or questions from parents will not be accepted. If you have ANY questions regarding paperwork or the general audition process, please contact the staff advisor in advance! Being proactive will insure you are prepared and cleared to participate in auditions. We are looking for well-rounded dancers with outstanding skills, technique and SCHOOL SPIRIT! Keep working on your skills! We look forward to meeting and working with you! GO SPARTANS! We discover and develop champions in life. -The Spartan Way

UNCG Dance Team Q&A Q: A: Q: A: Q: A: Q: A: Q: A: Q: A: Do you offer any partial or full scholarships for dancers? No scholarships are currently provided to UNCG Dance Team members. What is the UNCG Dance Team squad size? Our maximum squad size is 20 dancers. When are tryouts? The UNCG Dance Team holds tryouts in mid April. If needed, a Fall tryout will take place but will not always occur. What are the additional benefits of being a UNCG Dance Team member? The UNCG Dance Team is sponsored by the UNCG Athletic Department. Team members are able to pre-register for classes, have access to the Athletic Training room and staff, study hall sessions, strength and conditioning coaches, uniforms, shoes, travel accommodations and meal stipend when traveling and tickets to UNCG s home athletic events. Does your team compete? UNCG has competed at Nationals in the past. A decision has not been made if we will compete in 2017-18. Does your team attend summer camp? Yes, the UNCG Dance Team attends a summer camp. We discover and develop champions in life. -The Spartan Way

UNCG SPARTAN G'S AUDITION APPLICATION GENERAL INFORMATION NAME: (First, Middle, Last) UNCG STUDENT ID #: AGE: DATE OF BIRTH: (mm/dd/yy) CLASS RANK FOR THE 2017-18 ACADEMIC YEAR (circle one): FRESHMAN SOPHOMORE JUNIOR SENIOR OTHER UNCG E-MAIL ADDRESS: ALTERNATIVE E-MAIL ADDRESS: PERMANENT ADDRESS (PARENT S ADDRESS): (Street Address) (City) (State) (Zip Code) CELL PHONE #: HOME PHONE #: MAJOR: EXPECTED DATE OF GRADUATION: MOTHER S NAME: CELL PHONE #: FATHER S NAME: CELL PHONE #: ADDITIONAL INFORMATION DO YOU HAVE ANY CONFLICTS WITH THE TIME COMMITMENT AND EXPECTATIONS DURING THE SUMMER OR UPCOMING SEASON? (I.E. WEDDINGS, TRAVEL, STUDYING ABROAD, WORK COMMITMENTS) IF YES, PLEASE EXPLAIN: DO YOU HAVE ANY SPECIFIC HEALTH CONDITIONS OR LIMITATIONS WE SHOULD BE AWARE OF? IF YES, PLEASE EXPLAIN: HAVE YOU BEEN UNDER THE CARE OF A PHYSICIAN WITHIN THE PAST YEAR? IF YES, PLEASE EXPLAIN: Page 1

UNCG SPARTAN G'S SQUAD AUDITION APPLICATION DANCING BACKGROUND INFORMATION HOW MANY YEARS HAVE YOU BEEN DANCING? PLEASE LIST THE NAMES OF TEAMS, STUDIOS, ETC. YOU HAVE DANCED WITH IN THE PAST AND HOW MANY YEARS YOU WERE WITH THAT ORGANIZATION: TEAM/STUDIO NAME YEARS WITH ORGANIZATION 1. 2. 3. PLEASE LIST ANY ACCOMPLISHMENTS YOU HAVE EARNED THAT YOU WOULD LIKE US TO BE AWARE OF: LADIES UNIFORM INFORMATION UNIFORM TOP SIZE: o XS (30-32) S (32-34) M (34-36) L (36-38) UNIFORM SKIRT SIZE: o SMALL MEDIUM MEDIUM LONG LARGE JAZZ SHOE SIZE: o 5 7 9 5.5 7.5 9.5 6 8 10 6.5 8.5 TENNIS SHOE SIZE: 5 7 9 5.5 7.5 9.5 6 8 10 6.5 8.5 T-SHIRT SIZE: X-SMALL SMALL MEDIUM LARGE SWEATSHIRT SIZE: X-SMALL SMALL MEDIUM LARGE SWEAT PANT SIZE: X-SMALL SMALL MEDIUM LARGE WARM-UP JACKET SIZE: X-SMALL SMALL MEDIUM LARGE WARM-UP PANT SIZE: X-SMALL SMALL MEDIUM LARGE SPORTS BRA SIZE: XS (30-32) S (32-34) M (34-36) L (36-38) Page 2

Appendix B Sample print-out from UNCGenie: Your Name Here

Sample print-out from UNCGenie: Appendix B

UNCG CHEER AND DANCE PHYSICAL Name: Date: Sport: CHEER / DANCE School Address: University ID: DOB: Telephone Number: Parents Name: Parents Address: List any allergies (including latex): Last Tetanus: Medications currently taking (including birth control): *Please answer the questions below. Fill in details of yes answers in space provided.* 1. Have you ever been hospitalized? Yes No 2. Have you ever had surgery? Yes No 3. Have you ever passed out during exercise? Yes No 4. Have you ever been dizzy during exercise? Yes No 5. Have you ever had chest pain during exercise? Yes No 6. Have you ever had a head injury, seizure or unconscious? Yes No 7. Have you ever had heart trouble, or high blood pressure? Yes No 8. Has anyone in your family died suddenly before the age of 50 of heart problems? Yes No 9. Have you ever had a heat related illness?(cramps, dizzy or passed out) Yes No 10. Do you have any other medical problems?(ie asthma, diabetes, hepatitis, Impaired function of any organ) Yes No 11. Do you have any menstrual irregularities or problems? Yes No 12. Do you wear glasses, contacts, braces of any kind, orthotics, hearing aid? Yes No 13. Have you ever injured (sprained, dislocated, fractured etc)? Circle all that apply. Neck Chest Hip Thigh Knee Ankle Foot Toes Lower Leg Elbow Arm Wrist Back Head Fingers Shoulder

Page 2 EXAMINATION Height Weight RHR BP Heart Lungs Abdomen General Other MUSCULOSKELETAL Neck Back Shoulder Knee Elbow Ankle Wrist Foot Hip Hand ASSESMENT RECOMMENDATION CLEARANCE No Restrictions Deferred Until Name of Provider Signature of Provider Date

Appendix E Health Insurance Information for 2017-18 Academic Year Athlete s Name Date of Birth / / Last First MI Athlete s Home Address City State Zip Code Athlete s University ID # Athlete s SS# Sport Complete Name of Insurance Company Address to Mail Claim Policy Holder s Name Last First MI Policy Holder s Address Number Street City State Zip Code Policy Holder s SS# - - Policy Holder s DOB / / Please copy the front and back of your insurance card and affix it below. (Front) (Back)

Appendix F Consent to Disclose Protected Health Information I hereby consent to allow the UNCG Athletic Training Staff to disclose Protected Health Information concerning any injury or athletically related illness to my coaching staff and the UNCG Athletics Administration. I hereby consent to allow UNCG Athletic Department Personnel to disclose Protected Health Information concerning any injury or athletically related illness to my parents, legal guardians, or wards. I authorize payment of medical benefits to all providers of services for all services and materials they provide during the care of any injury/illness. I agree to supply any and all information requested by my primary insurance, UNCG and the excess insurance company, and the NCAA and their excess insurance company in a timely manner in order to expedite the claim process. I hereby authorize UNCG and their excess insurance company to secure and inspect copies of case history records, lab reports, diagnoses, x-rays, and other data pertaining to the injury/illness I am receiving care for or previous confinements, if disabilities relevant, to the care of the injury/illness. I authorize the UNCG Athletic Training staff and/or my coach to hospitalize and secure treatment for me for any athletic injury/illness. If the athlete is under 18 years of age, the undersigned parent/guardian grants permission the UNCG Athletic Training staff and/or the coach to hospitalize and secure treatment for their son/daughter/ward for any athletic injury/illness. This consent is irrevocable for the duration of any executed disclosure due to an athletically related illness or injury. A photo static copy of this consent shall be deemed as effective and valid as the original. I will notify the UNCG Athletic Training staff immediately upon any change in the above health insurance information. Athlete s Signature Parent/Guardian Signature Date Date Parent/Guardian s Name Relationship Home Phone Work Phone Parent/Guardian s Name Relationship Home Phone Work Phone Alternate Person to Contact in Case of Emergency Relationship Home Phone Work Phone

Appendix G UNCG Athletics Waiver, Release of Liability, & Indemnity Agreement I am aware and understand that any physical activity, including (but not limited to) soccer, basketball, volleyball, tennis, baseball, softball, cheerleading, weight lifting and conditioning, can be a dangerous activity, which may result in serious personal injury. These injuries include, but are not limited to, serious neck and spinal injuries, complete or partial paralysis, brain damage, serious injuries to bones, joints, ligaments, and tendons; serious injury to other areas of the body, general health and well-being, and even DEATH. In consideration of the University of North Carolina Greensboro (UNCG) permitting me to use its Athletic Facilities, I agree to the following: I will obey all rules established by UNCG Athletics for the use of its facilities. I will obey any and all instructions or directions given to me by UNCG Athletic personnel concerning the use of its facilities. I assume all financial responsibility for any injury or damage as a result of my use of UNCG Athletic Facilities. To the fullest extent allowed by law, I hereby release and agree to hold harmless UNCG, its trustees, officers, agents, employees, coaches, professors, students, athletic trainers and other medical personnel from any and all liability arising out of any injuries to my person or property, or losses of any kind or nature whatsoever, which may result from, or which arise in connection with, my use of the UNCG Athletic Facilities, even to the extent that such injuries may arise from the negligence of those listed above. To the fullest extent allowed by law, I will indemnify and hold harmless, including attorney s fees and court costs, those listed above for any injury to person or property that I may cause others in the course of my use of the UNCG Athletics Facilities or due to my failure to obey any rules, directions, or instructions. I acknowledge that I have read this agreement fully and that I understand the legal rights I waive by signing this agreement. I further acknowledge that I am aware of the potential hazards incident to engaging in physical activity. Signature of Participant Date Signature of UNCG Representative Date Printed Name of Participant Printed Name of UNCG Representative Printed Name of Parent/Guardian Date Signature of Parent/Guardian

Insurance Information 2017-2018 UNCG currently requires all students to have primary medical insurance. It is the responsibility of each student to prove that he/she has medical insurance, and if not, the student account will be automatically billed per semester. The premium has not been finalized for the 2017-18 year but will be announced this summer. We strongly recommend that you research and understand your insurance benefits prior to your arrival on campus. If the benefits are insufficient or non-existent in NC(HMO), you may wish to call your carrier to inquire about alternatives. Another option would be to choose/default to the school policy. Should the status of your insurance coverage change during the course of the school year, please be sure to communicate this with the athletic training staff immediately. The UNCG Department of Intercollegiate Athletics carries an excess insurance policy for each student-athlete to cover athletic related injuries. This policy carries a $0 deductible, per injury. When a student-athlete is injured during athletic participation, all medical insurance claims will be filed with your personal insurance company. Once your primary insurance company pays their portion of your bill, our excess policy will cover the remain-ing balance. In order to help process payments you may be required to provide the following: 1) Itemized bills from all medical providers 2) Explanations of Benefits (EOB s) from your medical insurance company All injuries must be reported to a staff athletic trainer. We will advise the student-athlete of the protocol that is recommended for treatment and referral, and as appropriate, steps necessary to best insure proper payment by all insurance parties involved. Please visit the student health center website to learn how to self-file charges incurred at the Student Health Center (SHC). The SHC charges are eligible for insurance coverage, but are not submitted by the provider. Please note that charges incurred for services at the SHC will be placed on the UNCG Student Account and lack of payment could affect future class registration, graduation etc. At no time should the student-athlete seek medical treatment without the prior approval of the Athletic Trainer. This action will jeopardize and/or remove responsibility from UNCG and its excess accident insurance company for payment of medical bills. Your signature on this letter indicates that you have read, understand and will comply with all that is stated above. Any false information will nullify UNCG from responsibility regarding any medical bills. I, have read the above letter and understand that UNCG is responsible on a secondary basis only for injuries which occur in an official UNCG athletic practice or competition. I also verify, that all of the insurance information I have provided is correct and complete. Student-Athlete Signature UNCG Student ID # Date Parent Signature Date

Appendix I 2017-2018 UNCG Intercollegiate Athletics Agreement, Injury Release, Assumption of Risk, and Athlete Responsibility Form UNCG Intercollegiate Athletic Sports: Baseball, Basketball, Cheerleading, Cross Country, Dance, Golf, Soccer, Softball, Tennis, Track & Field, Volleyball I am aware that trying out for, practicing or playing in any sport can be a dangerous activity involving MANY RISKS OF INJURY. I understand the inherent potential dangers and risks of trying out for, playing and practicing in the above intercollegiate sports may be catastrophic in nature and may include, but are not limited to, death; serious neck and spinal injuries which may result in complete or partial paralysis or brain damage; serious injury to virtually all bones, joints, ligaments, muscles, tendons and other elements of the muscular-skeletal system, including loss of limb; and serious injury or impairment to other parts of my body, general health and well-being. Because of the dangers of participating in any of the above sports, I recognize the importance of following the coach s instructions regarding playing techniques, training, rules of the sport and other team rules, and of following such instructions. I also realize that during my entire athletic career at UNCG I have a responsibility to my own physical well being and must accurately report any injury in a timely manner to the UNCG Sports Medicine Staff. I will follow the guidelines established by the UNCG Sports Medicine Staff for rehabilitation from any injury. If I have any questions regarding my injury or care, I will ask the UNCG Sports Medicine Staff. I will also abide by the rules of the sport in which I participate. I realize that adherence to these responsibilities in no way assures me of avoiding or lessening all injuries, including those of catastrophic nature, but by following them, I may decrease the severity of some injuries. In consideration of UNCG permitting me to try out for, practice, play or otherwise participate in the above listed intercollegiate sports and to engage in all activities related to the team, including, but not limited to practicing, playing and traveling, I hereby voluntarily assume all risks associated with participation and agree to hold harmless The University of North Carolina at Greensboro, its agents, officers and employees including, but not limited to, the UNCG Athletics staff from any and all liability, claims, causes of action or demands of any kind and any nature whatsoever which may arise by or in conjunction with my participation in any activities related to the UNCG Intercollegiate Athletics Program except in the event of their gross negligence. The terms of this Agreement shall serve as a release and assumption of risk for my heirs, estate, executor, administrators, assignees and all members of my family. To the best of my knowledge, I am in good health and suffer no disability or condition which renders my participation in the sport(s) or other athletics activity medically inadvisable, or otherwise limits my ability to participate in such sport(s) or athletics activity without restriction. I hereby authorize the coach or other appropriate UNCG personnel to obtain in my behalf first aid, emergency medical care, or if necessary admission to an accredited hospital, when such care is necessary for the treatment of any injuries I may sustain while participating in any activity associated with UNCG intercollegiate sports, including practices, competition and travel. I also hereby consent to the administration of emergency medical treatment in the event I am unable subsequent to such injury to give such consent as otherwise necessary. Name Signature Parent/Guardian Signature (if student-athlete is less than 18 years of age) Date of Birth Date Date

Appendix J UNIVERSITY OF NORTH CAROLINA at GREENSBORO SPORTS MEDICINE Sickle Cell Trait Screening Declination and Release of Claims **Must submit this form along with Sickle Cell Results (signing this form is NOT a replacement for testing, still must have Sickle Cell trait screening) About Sickle Cell Trait: Sickle cell trait is an inherited condition of the oxygen-carrying protein, hemoglobin, in the red blood cells. Sickle cell trait is a common condition (> three million Americans). Although Sickle cell trait is most predominant in African-Americans and those of Mediterranean, Middle Eastern, India, Caribbean, and South and Central American ancestry, persons of all races and ancestry may test positive for sickle cell trait. Sickle cell trait is usually benign, but during or after exercise, hypoxia(lack of oxygen) in the muscles may cause sickling of red blood cells (red blood cells changing from a normal disc shape to a crescent or sickle shape), which can accumulate in the bloodstream and logjam blood vessels, leading to collapse, personal injury and/or DEATH from the rapid breakdown of muscles starved of blood. If the UNCG Sports Medicine Staff and the student-athlete s coaches are made aware that a student-athlete has sickle cell trait, then collapse, personal injury and/or DEATH from exercise may be avoided or decreased if the student-athlete follows the directives of the Staff and his/her medical professionals. Such directives may include, but not be limited to, reduced or modified activity during practice and/or games. Sickle Cell Screening: If the student-athlete does not have knowledge of their sickle cell trait status, the NCAA recommends that screening is performed. In order to decrease the risk of collapse, personal injury and/or DEATH to its student-athletes, the University of North Carolina Greensboro requires that all student-athletes who do not know their sickle cell status undergo the screening. I,, (parent or guardian name here if student-athlete is under 18)understand and acknowledge that, in order to decrease the risk of collapse, personal injury and/or DEATH to its student-athletes the University of North Carolina at Greensboro recommends that all student-athletes have knowledge of their sickle cell trait status. Additionally, I have read and fully understand the aforementioned facts about sickle cell trait and sickle cell trait testing. I understand that exercising without knowledge of sickle cell trait status can increase the risk of collapse, personal injury and/or DEATH during or after exercise. I hereby affirm that I have fully and accurately disclosed in writing any prior medical history and/or knowledge of sickle cell trait status to UNCG Athletic Training staff. I do not wish to undergo sickle cell trait testing (in the case of a minor, the parent or guardian does not wish the minor to undergo sickle cell trait testing) through UNCG, as I (or my dependent) has been screened previously and I am able to provide these results. I (or in the case of a minor the parent or guardian) voluntarily agree to release, indemnify and hold harmless, regardless of their negligence, the State of North Carolina, the University of North Carolina at Greensboro, its officers, employees, agents and volunteers from any and all costs, liabilities, expenses, claims, demands, or causes of action on account of any loss, personal injury or DEATH that might result from this decision to not be screened for sickle cell trait and/ or from any incorrect information that I or any person on my behalf provided to UNCG Athletic Training staff about sickle cell trait status. I have read and signed this document with full knowledge that I may be giving up rights that I may otherwise be entitled to if I had not signed it. I am at least 18 years of age and competent to sign this waiver. Student-Athlete Signature Sport Parent/Guardian Signature Date Date University ID#