Piaa Member School Request For Decision On Athletic Eligibility Form Page 2
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1
2B.
This is a request for (check appropriate box[es]):
A determination as to the student’s eligibility
A waiver of ARTICLE I, Section 1 (Age Rule); ARTICLE III, Section 3 (Attendance Rule); or ARTICLE VIII,
Sections 1A and/or 1B (School Years and/or Seasons Limitation), of the PIAA By-Laws.
C. Please attach additional sheet(s) and specify, in narrative form, the situation in question. Where a request is made for
a waiver, please specify the reason(s) for such request.
D. Please list the names and titles, addresses, and telephone numbers of all persons who would or could give evidence
as the facts in this case.
NAME & TITLE
ADDRESS
TELEPHONE #
Section 4. Supporting Data/Documents
Please list and attach to this form copies of all supporting documents: e.g., transcripts, attendance records, physician’s
statements, psychiatric or psychological evaluations, etc.
Supporting data attached is as follows:
1.
2.
3.
4.
5.
6.
I certify that the above is an accurate and complete presentation of the facts in this case and ask the PIAA District
Committee that has jurisdiction over the aforementioned school to render a decision in this manner.
(Signature of PIAA Member School Principal)
(Date)
I certify that I have informed the student, and, if the student is under 18 years of age, that student’s parent(s) or
guardian(s), of my intent to file this request for a decision on athletic eligibility, and have afforded the student, and, where
applicable, that student’s parent(s) or guardian(s), the opportunity to provide information for this request and documents to
be attached to this form.
That opportunity was ___ exercised ___ declined by the student and was ___exercised ___declined by that student’s
parent(s) or guardian(s).
(Signature of PIAA Member School Principal)
(Date)
Principal’s E-Mail Address: ______________________________
NOTE: If sufficient space is not provided, please attach additional sheet(s) as necessary, identifying which items are
answered or continued on such sheet(s).
DO NOT WRITE BELOW THIS LINE
A. Date received at PIAA District ______ Office: ________/ ________/ ________.
B. Additional information requested: ________/ ________/ ________.
C. Additional requested information received at PIAA District ______ Office: ________/ ________/ ________.
D. Forwarded to PIAA District ______ Committee for action ________/ ________/ ________.
E. Final Decision ________/ ________/ ________.
APPROVED
DENIED (circle one)
F. Summary of PIAA District ______ Committee vote: ______ ayes ______ nayes ______ abstentions
G. Reason(s) for decision:
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