NORTHWEST ATHLETIC CONFERENCE

MEDICAL HARDSHIP WAIVER FORM

Use this form to request another season of sport participation under NWAC Code Article III, Section 26

The Northwest Athletic Conference (NWAC) would like to inform you of the following information as it pertains to your medical hardship request:

  1. It is important to understand that this appeal deals only with your athletic eligibility with NWAC member colleges. If you plan to continue your athletic competition at an NCAA or NAIA four-year college or university, you may not receive the same consideration; and if granted, your year of additional eligibility may be considered as an additional year of competition by the NCAA or NAIA.
  1. The NWAC would like to inform you that under the federal Health Insurance Portability and Accountability Act (HIPPA), you have the right to privacy regarding the sharing of your medical information. All medical information is confidential and will be used by authorized staff and trustees of the NWAC. The medical information used or disclosed will be specific to the injury/illness that is documented and being considered on this form.
  1. If you have any questions about this process, please first contact your coach and/or athletic director. If you need further clarification contact the NWAC office.

My signature below verifies that I have read and understand the consequences of my added eligibility according to NCAA rules.

______

Article III, Section 26 - A student-athlete may be granted an additional year of eligibility by the conference for reason of hardship which is defined as that incapacity resulting from injury or illness under the following conditions:

  1. Injury or illness occurs when he/she has not participated in more than 20% of games played.
  1. The injury or illness occurred in the first 50% of scheduled contests (pre-season games through the conclusion of regular season games, season not to include post-season contests).
  1. The injury resulted in incapacity to compete for the remainder of the season. The resulting injury mustbe documented by a doctor at the time of injury or on the date that the doctor determines the athletecan no longer compete during the season.
  1. The medical hardship requests will be accepted between the conclusion of the current sport season and the start of the following sport season.
  1. Student-athlete must meet all academic requirements as set forth by the NWAC codebook.

RE: In accordance with this section, to be considered for an additional season of sport, the student-athlete shall
have not participated in more than 20% of games played and the injury or illness occurred within the first
50% of scheduled contests (season not to include post-season contests).

COMPLETE THIS FORM AND PRESENT IT TO YOUR COLLEGE ATHLETIC COMMISSIONER

Your waiver request willnot be considered unless the following materials to support your request accompany this form:

1. A written statement from the student-athlete who is injured explaining the injury.

2. A written statement from the doctor that evaluated your injury or illness. Your trainer may present

additional information, but it cannot substitute for the doctor's record. The doctor's record must

include the dates of your injury or illness as cared for by him/her.

3. Up-to-date transcript(s) that verifies your academic standing.

4. An official athletic schedule for the sport season in which your injury or illness occurred indicating

indicating the contests in which you participated.

Student’s Name / Phone Number
Student’s Address / City, State, Zip
College / Sport / Date Injury/Illness Stopped Competition

How many scheduled contests (exclusive of scrimmages) did you participate in during the sports season prior to your incapacitating injury or illness?

Indicate on athletic schedule the contests in which you participated.

Is this your 1st or 2nd season in this sport? / 1st 2nd
Are you still enrolled? / Yes No
Credits Enrolled?

I verify that the above statements are true. I also understand that if granted, this request only affects my community college eligibility. I understand that I may not be granted an additional year of eligibility at a NCAA or NAIA college or university.

My signature below verifies that I have read and understand the consequences of my added eligibility according to NCAA rules and I understand the HIPPA policy.

Student Signature and Date College Official Signature and Date

Medical Hardship Form 2017