ATHELTICS DEPARTMENT
Student-Athlete Nutritional Supplement Disclosure and Review Form
I, _________________________________ am taking or intend to take the following
nutritional supplements. I acknowledge the risk of losing my eligibility to participate in
intercollegiate athletics if I test positive for an NCAA banned substance that may be
found in any substance that I may take, regardless of the reason or purpose for taking
such supplements.
I acknowledge and understand that the labeling on these products can be misleading and
inaccurate, and that sales personnel are paid to sell these products and cannot accurately
certify that these products contain no substance banned by the NCAA. Terms such as
“healthy” or “naturally occurring” do not necessarily mean safe to take or use, or that the
NCAA endorses a product or approves its usage. Before taking or using any supplement,
I am responsible for taking appropriate steps to ensure that it does not contain any
substance banned by the NCAA. Attaching a copy of the product label is helpful.
Brand Name: _________________________________________________________
Listed Ingredients:______________________________________________________
_____________________________________________________________________
_____________________________________________________________________
______________________________________________________________________
Please add an additional page to this form if you need more room.
______________________________________________ ________________
Student-Athlete’s Signature Date
______________________________________________________________________
Sport
OR
I, __________________________________ am NOT taking and DO NOT intend to
take any nutritional supplements. I understand that failure to declare nutritional
supplement usage may result in a loss of eligibility if the supplements taken contain any
substances banned by the NCAA. Should I begin taking supplements after this form has
been completed it is my responsibility to report any change in supplement usage to the
athletic department staff.
____________________________________________ _________________
Student-Athlete’s Signature Date
________________________________________________________________________
Sport
