East Carolina University Athletic Office of Compliance MEDICAL NONCOUNTER/MEDICAL HARDSHIP/FIVE-YEAR EXTENSION WAIVER REQUEST FORM
Student-athlete’s Name:
Sport:
Banner ID#:
Contact Phone Number:
Did the student-athlete participate in competition?
YES
or
NO
**Please note, a medical hardship waiver may not be sought if the student-athlete did not participate in competition.**
Type of waiver being requested:
Medical Hardship Medical Noncounter
Five-year clock extension
Signature of Head Coach:
Date:
Signature of Sport Admin:
Date:
Both
To Be Completed by Sports Medicine: Date of Initial Injury:
Injury Occurred During:
Practice
Competition
Other
Date of Initial Medical Evaluation: Has the student previously suffered an incapacitating injury: YES or NO
If yes, when:
Is the injury considered incapacitating: YES or NO If yes, are the following documents attached: - Signed statement by treating physician confirming the injury resulted in incapacity to compete: YES - Contemporaneous medical documentation (e.g. operation reports, treatment logs, etc.): YES
Signature of Sports Medicine Staff:
Date:
Office of Compliance Use Only: Student-athlete meets the maximum participation legislation:
YES
or
NO
Student-athlete was unable to participate in more than two seasons (if applicable):
YES
or
NO
Student-athlete is eligible for: Medical Hardship Five-year clock extension Medical Noncounter Signature: