Student-Athlete Statement - NCAA Division III 2024-25

For: Division III Student-athletes.
Action: Sign and return to your director of athletics.
Due Date: Before your first competition in Academic Year 2024-25.
Required By: NCAA Division III Bylaws 14.1.3 and 20.8.4.5.
Purpose: To assist in certifying eligibility.
Effective Date: The effectiveness of this NCAA Division III Student-Athlete Statement shall begin on the date of your signature and, unless terminated earlier in accordance with Part IX below, will continue until the earlier of your signature of a subsequent NCAA Student-Athlete Statement and your final date of participation in NCAA collegiate athletics.

Personal Information

Student Athlete's First Name

Student Athlete's Last Name

Mailing Address

Country

Street

City

Region

Postal Code

Date of Birth

Current age in years

Institution attending in Academic Year 2024-25

Sport(s)

If different than above, institution attending in Academic Year 2023-24

Information

Division III Bylaw 14.1.3.1 provides that, before participation in intercollegiate competition each academic year, a student-athlete shall sign a statement in a form prescribed by the Management Council in which the student athlete submits information related to eligibility, recruitment, financial aid, amateur status, previous positive drug tests administered by any other athletics organization, involvement in organized gambling activities related to intercollegiate and professional athletics competition under the Association's governing legislation. This is the annual form prescribed by the Management Council and it includes the following ten parts:

I. General Statement Concerning Eligibility
lI. FERPA/HIPAA Consent
III. Amateurism
IV. Drug Tests
V. Sports Wagering
VI. Academic Eligibility Information (First Year Only)
VII. Other Prior Violations
VIII. Information Pertaining to Future Transfer
IX. Termination/Survivability of Student-Athlete Statement
X. Student-Athlete Signature

Bylaw 14.1.3.1 provides that a failure to complete and sign the annual eligibility statement shall result in the student-athlete's ineligibility for participation in all intercollegiate competition. Accordingly, you must legibly complete the information above and sign all parts below in order to be eligible to participate in intercollegiate competition. Before you sign this form, you should read the eligibility provisions of the NCAA Division III Manual or the Summary of NCAA Key Regulations, or another similar outline or summary of NCAA regulations, in each case in the form provided to you by your director of athletics. You are responsible for knowing and understanding the application of all NCAA Division III regulations related to your eligibility. If you have any questions, you should discuss them with your director of athletics. The conditions that you must meet to be eligible and the requirement that you sign this form are indicated in the following articles and regulations of the Division III Manual: NCAA Bylaws 10 (Ethical Conduct), 12 (Amateurism), 13 (Recruiting), 14 (Eligibility), 15 (Financial Aid), 16 (Awards, Benefits, Expenses), 18.4 (Championship Eligibility) and 31.2.3 (Banned Substances).

If you have questions, you may contact the NCAA directly at 317-917-6222.

PART I: GENERAL STATEMENT CONCERNING ELIGIBILITY.

I affirm the following:

My current institution identified above has provided me with a copy of the Summary of NCAA Key Regulations, or another similar outline or summary of the eligibility regulations of the Division III Manual, and my director of athletics (or their designee) provided me with an opportunity to ask questions about those materials.
I have knowledge of and understand the application of the Division III regulations as they relate to my eligibility to participate in intercollegiate athletics.
To the best of my knowledge, I meet the eligibility requirements to participate as a student-athlete in NCAA Division III collegiate athletics including those related to ethical conduct, amateurism, recruiting, eligibility, financial aid, awards and benefits, banned substances and sports wagering, in each case as those requirements are described in the Division III manual sections identified above.
I understand that if I sign this statement falsely or erroneously it will result in a violation of NCAA regulations regarding ethical conduct which will jeopardize my eligibility to participate in intercollegiate athletics.

PART II: FERPA/HIPAA CONSENT.

1. Required FERPA Consent – Institutional Education Record Disclosure for Eligibility Purposes.
I understand that education records are protected by the Family Educational Rights and Privacy Act of 1974 as the same may be amended from time to time (FERPA) and may not be disclosed without my consent. I agree that my current institution identified above may disclose this form, the other education records information described in items (a)-(k) below, and any other documents or information related thereto, to its conference (if any), the NCAA, and their respective authorized agents solely for the purpose of permitting those authorized recipients to evaluate, determine and/or confirm my eligibility for any aspect of participation in NCAA intercollegiate athletics and related programs:

a. Results of drug tests administered by the NCAA, its authorized agents or my current institution identified above, and related information and correspondence including, without limitation, the information provided in Part IV below;
b. Results of drug tests administered by a non-NCAA national and international sports governing body including, without limitation, the information provided in Part IV below;
c. Any transcript from my high school, the identified institution, or any junior college or any other four-year institution I have attended;
d. Pre-college test scores, appropriately related information and correspondence (e.g., testing sites and dates and letters of test-score certification or appeal) and where applicable, information relating to eligibility for or conduct of nonstandard testing;
e. Graduation status;
f. My social security number and/or student identification number;
g. Race and gender identification;
h. Diagnosis of any education-impacting disabilities;
i. Accommodations provided or approved, and other information related to any educationimpacting disabilities in all secondary and postsecondary schools;
j. Records concerning my financial aid; and
k. Any other materials or information disclosed by me or otherwise received pertaining to my NCAA eligibility.

2. Required HIPAA Consent – Institutional Health Care Disclosure for Eligibility Purposes.
I understand that certain of my health-related information is protected by the Health Insurance Portability and Accountability Act of 1996 as the same may be amended from time to time (HIPAA) and may not be disclosed without my consent. I agree that my current institution identified above, and any of its physicians, athletic trainers and other agents, as well as any health care organizations and medical personnel that may be working with it or providing services on its behalf, may disclose my Protected Health Information, as that term is defined in 45 C.F.R§ 160.103, to the NCAA and its authorized agents and representatives to the extent such information pertains to my participation in collegiate athletics including, without limitation, any information regarding any injury, illness or any diagnosis, or any treatment or management of any injury or illness, related to or affecting my training for and participation in intercollegiate athletics, for the sole purpose of evaluating determining and/or confirming my eligibility for any aspect of participation in NCAA intercollegiate athletics and related programs.

3. Voluntary FERPA/HIPAA Consent (Check One/Both of the First Two Boxes OR the Third Box Below).

Optional Disclosure for Awards and Recognition Purposes. In addition to my FERPA/HIPAA consents to disclosure above which are required for eligibility purposes, and which are limited in scope to purposes related to my eligibility for participation in collegiate athletics, I agree that my current institution identified above may disclose the education records information described in items 1(a)-(k) above and any other documents or information related thereto, to its conference (if any), the NCAA, and their respective authorized agents solely for the purpose of permitting those authorized recipients to evaluate, determine and/or confirm evidence that may support certain conference and/or NCAA awards and other recognition.

Optional Disclosure for Research Purposes. In addition to my FERPA/HIPAA consents to disclosure above which are required for eligibility purposes, and which are limited in scope to purposes related to my eligibility for participation in collegiate athletics, I agree that my current institution identified above and any of its physicians, athletic trainers and other agents, as well as any health care organizations and medical personnel that may be working with it or providing services on its behalf, may disclose my injury/illness and participation information associated with my training and participation in intercollegiate athletics to the NCAA and to its Injury Surveillance Program (ISP), agents and employees for the sole purpose of conducting research into the reduction of athletics injuries.

OR No Additional Consent to Disclosure. I do not consent to any disclosure other than for the purposes described in Sections 1 and 2 above. I understand that no additional consent is required for purposes of maintaining my eligibility or for receipt of or payment for institutional medical treatment, or enrollment in or receipt of benefits under any institutional health or benefit plan, as the same may be applicable.

4. Institutional Disclosure of Deidentified Information.
I understand and agree that, while not subject to FERPA or HIPAA, certain portions of my education record data and information may be disclosed by my current institution identified above on a deidentified basis to the NCAA in connection with, among other things, longitudinal research studies and compliance activities.

5. Subsequent NCAA Disclosure.
I acknowledge and understand that the NCAA may further disclose the information that it properly receives pursuant to the consents set forth in this Part II including, among other things, information regarding any NCAA reinstatement, infractions or waiver matter in which I may become involved while I am a student-athlete, to the media, its committee members or any other third party: (a) for the purpose of evaluating, determining and/or confirming my eligibility for any aspect of participation in NCAA intercollegiate athletics and related programs; (b) to confirm, or correct any inaccuracy in, any statement reported publicly and related to any such matter; (c) with respect to any information it receives pursuant to Section 3 above, to recognize my selection for an NCAA administered award (e.g., Elite 90); (d) without identifying me by name, to the extent required by NCAA regulations, policies or procedures; or (e) as may otherwise be required by law.

PART III: AMATEURISM.

1. Future Violations.
I affirm that I have read and understand the NCAA amateurism rules and I agree that I will promptly report to the director of athletics of my current institution identified above any violation of any such rule that occurs at any time after I sign this statement and while I am a student-athlete at the identified institution.

2. Historical Violations (Check One Box Below).

No Violation. I affirm that to the best of my knowledge, I have not violated any NCAA amateurism rules; and have not provided false or misleading information concerning my amateur status to the NCAA or my current institution identified above or any person working for or on behalf of those organizations.

Prior Violation. I am disclosing that I have violated one or more NCAA amateurism rules and/or have provided false or misleading information concerning my amateur status to the NCAA or my current institution identified above or one or more persons working for or on behalf of those organizations and I have reported or will promptly report the details related to such violation(s) to the director of athletics at my current institution identified above including, along with any other related information requested by the institution, the date(s) and nature of those violation(s) and the identity of those organizations and individuals who were involved.

PART IV: DRUG TESTS.

1. Future Positive Drug Test Results.
I am aware of the NCAA drug-testing program. I have read and understand the related eligibility requirements and restrictions and I have signed the 2023-24 Drug-Testing Consent Form (Form 21-3f). I agree that I will report my results and/or actions to the director of athletics of my current institution identified above in the event that I, at any time after I sign this statement and while I am a student-athlete at the identified institution: (a) test positive as part of any drug test administered by the NCAA, my current institution identified above or any of their respective authorized agents or representatives, and/or by or at the direction of any non-NCAA athletics organization or national or international athletics governing body; or (b) fail to appear for any scheduled drug test, or otherwise violate the drug-testing protocol, of any of these parties.

2. Historical Drug Test Results (Check One Box Below).

No positive drug test. I affirm that I have never: (a) tested positive as part of any drug test administered by the NCAA, my current institution identified above or any of their respective authorized agents or representatives, or by or at the direction of any non-NCAA athletics organization or national or international athletics governing body; or (b) failed to appear for a scheduled drug test, or otherwise violated the drug-testing protocol, of any of these parties.

Positive drug test. I am disclosing that I have: (a) tested positive as part of a drug test administered by the NCAA, my current institution identified above or any of their respective authorized agents or representatives, and/or by or at the direction of any non-NCAA athletics organization or national or international athletics governing body; and/or (b) failed to appear for a scheduled drug test or otherwise violated the drug-testing protocol, of one or more parties. I have reported or will promptly report the details of the testing and results of my current institution identified above including, along with any other related information requested by the institution: 1. The date(s) of such test(s); 2. The testing institution(s)/organization(s); 3. The substance(s) detected; 4. The details and finding(s) of any retest(s) or appeal(s); 5. The start and end date(s) and current status of any resulting suspension.

PART V: SPORTS WAGERING.

1. Future Sports Wagering Activity.
I affirm that I have read and understand the NCAA sports wagering rules, and I agree that if I violate the sports wagering rules of the NCAA and/or any non-NCAA national or international athletics governing body at any time after I sign this statement while I am still a student-athlete at my current institution identified above I will promptly report this information to the director of athletics at the identified institution

2. Historical Sports Wagering Suspension (Check One Box Below)

No Sports Wagering-Related Suspension. I affirm that I have never been subject to any suspension related to a violation of any NCAA and/or non-NCAA national or international athletics governing body sports wagering rule.

Sports Wagering-Related Suspension. I have been subject to a suspension related to a violation of NCAA and/or a non-NCAA national or international athletics governing body sports wagering rules, and I have reported or will promptly report details of the testing and results of my current institution identified above including, along with any other related information requested by the institution: 1. The suspending institution(s)/organization(s); 2. The sport(s) wagered on and date(s)/location(s) of wagering activity; 3. The details and finding(s) of any appeal(s); 4. The start and end date(s) and current status of such suspension(s).

PART VI: ACADEMIC ELIGIBILITY INFORMATION (First Year Only).

I affirm that, to the best of my knowledge, all information provided to my current institution identified above by me or on my behalf and related to my academic eligibility including, without limitation, information pertaining to test scores, high school attendance, completion of coursework and high school grades, is complete, valid and accurate.

PART VII: OTHER PRIOR VIOLATIONS (Check One Box Below).

Other than any violations that I have disclosed above in this form, or in a previous Student-Athlete Annual Statement form that I signed and delivered to my current institution identified above in a prior academic year, I am not aware that I have been involved at any time in any NCAA violations.

In addition, any NCAA violations that I have disclosed above in this form, or in a previous StudentAthlete Annual Statement form that I signed and delivered to my current institution identified above in a prior academic year, I am aware that I have been involved with one or more other NCAA violations, and I have reported or will promptly report the details related to such violation(s) to my current institution identified above including, along with any other related information requested by the institution: 1. The date(s) and nature of those violation(s); 2. Copies of any communications or other documents or materials related to the violation(s); 3. The start and end date(s) and current status of any related NCAA or institutional investigation; 4. The effective date and details pertaining to any resulting NCAA or institutional suspension or other penalty.

PART VIII: INFORMATION PERTAINING TO FUTURE TRANSFER.

I consent and agree to disclose to authorized representatives of my current institution identified above any documents or information pertaining to my NCAA transfer eligibility and to allow authorized representative(s) of that institution to disclose my transfer status, the information in this form and any other information that may be part of my education records pertaining to my NCAA transfer eligibility to its conference (if any), the NCAA, other NCAA member institutions and their respective authorized agents for the purposes of facilitating any future transfer that I may pursue.

PART IX: TERMINATION/SURVIVABILITY OF STUDENT-ATHLETE STATEMENT.

I understand that I may for any or no reason, by providing written notice of the same to the director of athletics at my current institution identified above, voluntarily terminate the effectiveness of this StudentAthlete Statement and, relatedly, all of the agreements, consents and other representations contained in this form, with the understanding that any termination under this Part IX will automatically and simultaneously terminate my eligibility to participate in NCAA collegiate athletics. Any termination attempted under this Part IX will be effective upon the receipt of the required notice by the identified institution's director of athletics.

NOTE: Notwithstanding anything to the contrary in this Statement, I agree that my consents and other representations described in Sections 1, 2 and 5 of Part II above will, solely for the purposes described in those Sections, survive and remain effective even after any termination or expiration of this Statement.

PART X: STUDENT-ATHLETE ELECTRONIC SIGNATURE

I agree that I have had an adequate opportunity to read the entire content of this Student-Athlete Statement and to discuss the same and any questions I have with my director of athletics and other/or other advisors, and my signature below reflects my understanding of, and agreement with the same.

In place of your signature, please type your full legal name as your electronic signature:

Signature of parent or legal guardian (if student-athlete is a minor). Please type your full legal name as your electronic signature: