Medical Hardship Waiver Petition
MEDICAL EXEMPTION FORM Conference Staff Only Further Information Needed: ___________________________
Granted: ________
Conference Official:___________________________________________________
Denied: _______ Date:_____________
I. Summary Institution: Student-Athlete Name:
Sport:
For Academic Year:
Date Submitted:
II. NCAA Bylaw 15.5.1.3
A counter who becomes injured or ill to the point that he or she apparently never again will be able to participate in intercollegiate athletics shall not be considered a counter beginning with the academic year following the incapacitating injury or illness. If circumstances change and the student-athlete subsequently practices or competes at the institution at which the incapacitating injury or illness occurred, the student-athlete again shall become a counter, and the institution shall be required to count that financial aid in the sport in question during each academic year in which the financial aid was received. The Legislative Council Subcommittee for Legislative Relief may waive the requirements of Bylaw 15.5.1.3.2 upon determination that sufficient documentation is available from competent medical authorities to indicate that the original injury or illness clearly appeared to be incapacitating and that there was no reasonable expectation that the student-athlete ever again would be able to participate in intercollegiate athletics.
III. Physician's Statement
Attached to this completed form must be a signed statement on the physician's letterhead that includes all of the following: 1. Date of injury or onset of illness; 2. Diagnosis of injury or illness; 3. Language that states the severity of injury or illness prevents any further competition; and 4. Reasons as to why the injury or illness will prevent further competition.
IV. Student-Athlete Statement
I fully understand the conditions of being classified as an exempted player and that the diagnosis of the injury/illness clearly appears to be incapacitating and that there is reasonable expectation that I will never again be able to participate in intercollegiate athletics. Furthermore, I understand that while I may continue to receive financial aid, if circumstances change and I am again able to practice or participate in any sport, I must be counted per NCAA Bylaw 15.5.1.3.2.
V. Additional Comments
__________________________________________________
Student-Athlete Signature
Date
__________________________________________________
Compliance Officer Signature
Date
When approved, copies of this form are to be provided to the student-athlete and retained in the Athletic Department.
Granted: ________
Conference Official:___________________________________________________
Denied: _______ Date:_____________
I. Summary Institution: Student-Athlete Name:
Sport:
For Academic Year:
Date Submitted:
II. NCAA Bylaw 15.5.1.3
A counter who becomes injured or ill to the point that he or she apparently never again will be able to participate in intercollegiate athletics shall not be considered a counter beginning with the academic year following the incapacitating injury or illness. If circumstances change and the student-athlete subsequently practices or competes at the institution at which the incapacitating injury or illness occurred, the student-athlete again shall become a counter, and the institution shall be required to count that financial aid in the sport in question during each academic year in which the financial aid was received. The Legislative Council Subcommittee for Legislative Relief may waive the requirements of Bylaw 15.5.1.3.2 upon determination that sufficient documentation is available from competent medical authorities to indicate that the original injury or illness clearly appeared to be incapacitating and that there was no reasonable expectation that the student-athlete ever again would be able to participate in intercollegiate athletics.
III. Physician's Statement
Attached to this completed form must be a signed statement on the physician's letterhead that includes all of the following: 1. Date of injury or onset of illness; 2. Diagnosis of injury or illness; 3. Language that states the severity of injury or illness prevents any further competition; and 4. Reasons as to why the injury or illness will prevent further competition.
IV. Student-Athlete Statement
I fully understand the conditions of being classified as an exempted player and that the diagnosis of the injury/illness clearly appears to be incapacitating and that there is reasonable expectation that I will never again be able to participate in intercollegiate athletics. Furthermore, I understand that while I may continue to receive financial aid, if circumstances change and I am again able to practice or participate in any sport, I must be counted per NCAA Bylaw 15.5.1.3.2.
V. Additional Comments
__________________________________________________
Student-Athlete Signature
Date
__________________________________________________
Compliance Officer Signature
Date
When approved, copies of this form are to be provided to the student-athlete and retained in the Athletic Department.
