Name *

Sex *

Permanent Address *

Local Address

Leave blank if same as permanent address.

Phone *


If immigrant or non-immigrant is selected, please fill out the country box below.

Have you ever been convicted of a felony?


e.g. Cincinnati, Ohio

e.g. August 2012

e.g. December 2012

Currently enrolled? *

If you are not a current Xavier University student, include your latest transcript below via a Word document. If you do not have an electronic copy, mail a copy to the Xavier University Department of Sports Studies, 3800 Victory Parkway, Cincinnati, Ohio 45207-6312.

If you are not a current Xavier University student please mail an official transcript with the other required forms to Xavier University Department of Sports Studies, Attention: Peggy Eichhold, 3800 Victory Parkway, Cincinnati, Ohio 45207-6312. If you have an electronic copy, please submit that file via a PDF document.


Emergency contact name *

Emergency contact address *

Emergency contact phone *

I certify that the information in this application is accurate and true. I authorize Xavier University’s International Education Center (CIE) to access my academic records and to contact appropriate personnel to verify that I am under no disciplinary action or have judicial cases pending against me. *