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Student-Athlete Statement NCAA Division III Action: Sign and (City of Oakland)

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Form 21-3c Academic Year 2021-22
Student-Athlete Statement − NCAA Division III
Student-Athlete’s Full Name (Print):
Home address (street or P.O. Box) Home city, state, and zip code
Date of birth Current age in years
Institution attending in academic year 2021-22
Sport(s)
If different than above, institution attended in academic year 2020-2021
D
ivision 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 and 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. Ge
neral Statement Concerning Eligibility
II. FERPA/HIPAA Consent
III. Amateurism
IV. Drug Tests
V. Sports Wagerin
g
V
I. 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
For: Division III Student-athletes.
Action: Sign and return to your director of athletics.
Due Date: Before your first competition in Academic Year 2021-22.
Required By: NCAA Division III Constitution 3.2.4.5 and Division III Bylaw 14.1.3
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.
NCAA Division III Student-Athlete Statement
Form 21-3c
Page No. 2
_________
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.
B
efore you sign this form, you should read the eligibility provisions of the NCAA Division III Manual or
the Summary of NCAA 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).
I
f you have questions you may contact the NCAA directly at 317-917-6222.
PART I: GENERAL STATEMENT CONCERNING ELIGIBILITY.
I
affirm the following:
1. My current institution identified above has provided me with a copy of the Summary of NCAA
R
egulations, or another similar outline or summary of the eligibility regulations of the Division III
Manual, and my director of athletics (or his or her designee) provided me with an opportunity to
ask questions about those materials.
2. I ha
ve knowledge of and understand the application of the Division III regulations as they relate to
my eligibility to participate in intercollegiate athletics.
3. T
o 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.
4. 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. R
equired 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
NCAA Division III Student-Athlete Statement
Form 21-3c
Page No. 3
_________
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 your high school, the identified institution, or any junior college or
any other four-year institution you have attended;
d. Pr
e-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. Y
our social security number and/or student identification number;
g. Race and gender identification;
h. D
iagnosis of any education-impacting disabilities
;
i. A
ccommodations provided or approved, and other information related to any education-
impacting disabilities in all secondary and postsecondary schools;
j. Records concerning your financial aid; and
k. A
ny other materials or information disclosed by you or otherwise received pertaining to
your NCAA eligibility.
2. R
equired 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
,
a
nd 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,
NCAA Division III Student-Athlete Statement
Form 21-3c
Page No. 4
_________
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
F
ERPA/HIPAA consents to disclosure above which are required for eligibility purposes
,
a
nd which are limited in scope to purposes related to my eligibility for participation i
n
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 t
o
ev
aluate, 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 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. I
nstitutional 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. S
ubsequent NCAA Disclosure.
I
acknowledge and understand that the NCAA may further disclose the information that it properl
y
r
eceives 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-
NCAA Division III Student-Athlete Statement
Form 21-3c
Page No. 5
_________
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. Fut
ure Violations.
I a
ffirm that I have read and understand the NCAA amateurism rules and I agree that I will promptl
y
r
eport 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.
OR
☐ 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 identify of those organizations and individuals who
were involved.
P
ART IV: DRUG TESTS.
1. Fut
ure 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 2021-22 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
NCAA Division III Student-Athlete Statement
Form 21-3c
Page No. 6
_________
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.
OR
☐ 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 schedule drug test, or otherwise violated the drug-testing protocol,
of one or more of these parties. I have reported or will promptly report the details of th
e
t
esting and results of my current institution identified above including, along with any other
related information requested by the institution:
• Th
e date(s) of such test(s)
• The testing institution(s)/organization(s)
• The substance(s) detected
• The details and finding(s) of any retest(s) or appeal(s)
• The start and end date(s) and current status of any resulting suspension
PART V: SPORTS WAGERING.
1. Fut
ure 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.
OR
☐ 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:
• t
he suspending institution(s)/organization(s)
• the sport(s) wagered on and date(s)/location(s) of wagering activity
NCAA Division III Student-Athlete Statement
Form 21-3c
Page No. 7
_________
• the details and finding(s) of any appeal(s)
• 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.
OR
☐ In addition any NCAA 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 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:
• the date(s) and nature of those violation(s)
• copies of any communications or other documents or materials related to the violation(s)
• the start and end date(s) and current status of any related NCAA or institutional
investigation
• 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.
NCAA Division III Student-Athlete Statement
Form 21-3c
Page No. 8
_________
NCAA/05.26.2021/LF:jn
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 Student-
Athlete 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 this
Statement.
PART X: STUDENT-ATHLETE 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.
Signature of student-athlete Date
Signature of parent or legal guardian (if student-athlete is a minor) Date
What to do with this form: Sign and return it to your director of athletics (or his or her designee) before your
first competition. This form is to be kept in the director of athletics’ office for six years.
Any questions regarding this form should be referred to your director of athletics or your institution’s
NCAA compliance staff or you may contact the NCAA directly at 317-917-6222.
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Student-Athlete Statement NCAA Division III Action: Sign and (City of Oakland)

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Completed 19 July 2021

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