Fillable Pepperdine Promotional Activity Form University of Southern California

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Pepperdine Promotional Activity Form University of Southern California

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Updated 2.18.13
PROMOTIONAL ACTIVITY FORM
_____________________________________________________________________________
This form must be completed prior to any Pepperdine student-athlete’s involvement in a promotional or fundraising
activity. Please submit to the Compliance Office at least seven (7) days prior to the event. Email to
brian.barrio@pepperdine.edu or fax to (310)-506-7459.
_____________________________________________________________________________
Name of Institutional/Charitable/Educational/Non-Profit Organization:
_____________________________________________________________________________
Agency Contact Information:
Name: _____________________________ Title:_____________________
Street Address: __________________________________________________________
City, State, Zip: __________________________________________________________
Phone: _________________________________________________________________
Athletic Department Contact: _______________________________________________
Promotional Activity or Project:
______________________________________________________________________________
______________________________________________________________________________
Date/Time/Location:
______________________________________________________________________________
Promotional Activities Involving Student-Athletes
NCAA rules require Pepperdine University to present written approval for any student-athlete participating in any
institutional, or non-institutional charitable, educational, or non-profit activity or project considered incidental to the
student-athlete's participation in intercollegiate athletics.
Pepperdine University, the West Coast Conference, or a non-institutional charitable, educational, or non-profit agency
may use a student-athlete's name, picture, or appearance to support its charitable or educational activities, but as
stipulated under NCAA rules, a Pepperdine student-athlete may participate in an institutional, or non-
institutional charitable, educational, or non-profit promotion only under the following conditions:
1. Student-athlete receives written approval to participate from the Director of Athletics (or designee), subject to the
limitations on participants in such activities as set forth in the NCAA regulations;
2. The specific activity or project in which the student-athlete participates does not involve co-sponsorship,
advertisement, or promotion by a commercial agency. The sponsoring organization may reproduce their regular
trademark or logo (along with their address and telephone number) only on printed materials such as pictures,
posters, or calendars;
3. The name or picture of a student-athlete with remaining eligibility may not appear on an institution's printed
promotional item (e.g., poster, calendar) that includes a reproduction of a product with which a commercial entity
is associated if the commercial entity's officially registered regular trademark or logo appears on the item;
Updated 2.18.13
4. Student-athlete does not miss class;
5. All monies derived from the activity or project go directly to Pepperdine, the West Coast Conference, or the
charitable, educational, or non-profit agency;
6. Student-athlete's name, picture, or appearance is not utilized to promote the commercial ventures of any nonprofit
agency;
7. Student-athlete and an authorized representative of the charitable, educational, or non-profit agency must sign a
release statement ensuring that the student-athlete's name, image, or appearance will not be used for any
commercial purpose;
8. Approval of this activity does not guarantee the appearance of a Pepperdine student-athlete.
Brief description of the duties the student-athlete will be performing for the activity or
project: (Attach additional information, if available.)
_____________________________________________________________________________
_____________________________________________________________________________
Will the student-athlete(s) miss class? Yes No
Will the student-athlete(s) receive any expenses (meals, transportation)? Yes No
If yes, please list expenses received: ________________________________________________________
Will the student-athlete(s) receive any gifts or awards? Yes No
If yes, please list the gifts/awards received: __________________________________________________
Will there be any commercial sponsorship of this event? Yes No
Will there be any advertisement or promotions by a commercial agency or sponsor? Yes No
Will the student-athlete(s) attendance at this activity mandatory? Yes No
(If mandatory, these hours MUST be included on the NCAA time logs.)
How many hours will each student-athlete be involved with the activity? _________________
Co-sponsorship or Advertising for this Event (describe printed materials, commercial trademarks or logos):
__________________________________________________________________________________________
__________________________________________________________________________________________
Will all monies generated by the activity go directly to the sponsoring agency: Yes No
If “No”, please describe where the monies will go: __________________________________________________
Student-Athletes Involved (attach additional sheets if necessary)
I have been advised that I run the risk of losing my athletic eligibility if I do not adhere to the above guidelines.
Print Name Signature Sport
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Updated 2.18.13
I certify that I understand the above statements, and will not risk the eligibility of the named
student-athlete(s) by having him/her participate in any activities that do not adhere to the above
guidelines.
Signed Title Date
___________________________________________________________________________
(Athletic Department Supervisor or Coordinator)
I have read and agree to these NCAA requirements on the use of a student-athlete’s name, picture
or appearance to promote a charitable or educational activity.
Name Title
______________________________________________________________________________
(Authorized Agency Representative)
Signature Date
______________________________________________________________________________
This institutional, or non-institutional charitable, educational, or non-profit activity meets the
requirements of NCAA 12.5.1.1.
Signed Date
______________________________________________________________________________
(Compliance Office)
I authorize the participation of the named student-athlete in the above named institutional, or
non-institutional charitable, educational, or non-profit activity.
Signed Date
______________________________________________________________________________
(Director of Athletics-or their designee)
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Pepperdine Promotional Activity Form University of Southern California

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Completed 18 November 2019

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