PLAYER COMPLIANCE

Personal Information:

High School Information:

Additional Information:

List ALL Colleges Attended Full-Time and/or Part-Time after High School

All transcripts from all previous institutions must be included.

Additional Explanations:

NOTE: If you attended college part-time or were not attending at all for any periods of time following high school graduation, please document your employment, military history and or mission work during those times. If you were unemployed at any time, please list those dates as well. The NPGAA requires that we account for any time not enrolled full-time. Please use the space below. Please record months and years when referring to dates.

HIPAA/FERPA Uses and Disclosures of Student-Athlete Protected Information Form FAQ’s

What is this form?

This form was developed based on the Health Insurance Portability & Accountability Act of 1974, 1996 (HIPPA) and the Family Education Rights and Privacy Act of 1974 (FERPA).

1.) FERPA

FERPA is a federal law that protects the privacy of student education records. The Family Education Rights and Privacy Act was enacted by Congress to protect the privacy of student educational records. This privacy right is a right vested in the student. Generally:

• Institutions must have written permission from the student in order to release any information from a student’s educational record.
• Institutions may disclose directory information in the student’s educational record without the student’s consent.
• It is good policy for the institution to notify the student about such disclosure and to seek the written permission of the student to allow disclosure of any educational records including directory information.
• Institutions should give the student ample opportunity to submit a written request that the school refrain from disclosing directory information about them.
• Institutions must not disclose non-directory information about students without their written consent except in very limited circumstances.
• Institutions should notify students about their rights under FERPA through annual publications.
• When in doubt, it is always advisable to err on the side of caution and to not release student educational records without first fully notifying the student about the disclosure.

2.) HIPAA

HIPAA was enacted by the U.S. Congress in 1996 to address the security and privacy of health data. This piece of legislation was put into place for many reasons including the following:

• Insure health insurance portability.
• Reduce healthcare fraud and abuse.
• Guarantee security and privacy of health information.
• Enforce standards for health information MAINLY, to protect health information from disclosure.

**This legislation unintentionally impacted athletics because of the medical aspect of care**

1.) Why do we have this form?

By signing this form the student-athlete is authorizing their direct supervising Certified Athletic Trainer/Team Physician and/or Insurance Coordinator (Sports Medicine Staff) to communicate with the identified entities as explained in this document when it pertains to the individual throughout the year.

****This does not mean that ANY and/or ALL of medical information can and will be disclosed. The only information that will be disclosed is that of absolute necessity per situation.****

In Example:

For Insurance Purposes: Insurance coordinator to correspond with insurance companies to facilitate outside care. This may include but is not limited to: preauthorizing diagnostic testing, surgeries, ensuring proper insurance protocol to coordinate referral appointments as needed.

For the Coaching Staff: If an injury occurs during a practice or competition, this form authorizes the Sports Medicine Staff working with your son or daughter to communicate with the coach regarding the status of return.

For the Media: It is not our policy to inform the media of any injury or illness conditions without prior consultation with the student-athlete.

2.) Who discloses what information and to whom?

The only people who are authorized to disclose information are the student-athlete’s Certified Athletic Trainer, Team Physician or Insurance Coordinator as it pertains to the situation that may arise. See examples above.

Any information about past injuries/conditions will only be disclosed as it would pertain to participation in the present. In example: Low back injuries that would limit weight training or conditioning.

PART II: FERPA CONSENT.

The Family Educational Rights and Privacy Act of 1974 (“FERPA”) gives you certain confidentiality rights with respect to your education records. Generally, the NPGAA must have your written permission before it may release any confidential information from your education records. There are, however, exceptions. For instance, the NPGAA can release “Directory Information” about you without your consent. Directory Information is information that would not be considered harmful or an invasion of privacy if disclosed. Examples include your name, address, telephone number, date and place of birth, honors and awards, and dates of attendance. Subject to the limitations of this Consent Form, the NPGAA and its affiliates seeks to release limited relevant information about you to meet its obligations to the NPGAA and its affiliate athletic or academic organizations in which it participates, or for federally mandated reporting purposes.

In addition, the NPGAA seeks your consent to make limited releases regarding your ability to participate in athletic programs or to correct inaccurate statements made by the media, including information related to suspensions or dismissals from a team. Although you may specifically authorize such releases, the NPGAA may elect not to release such information at its discretion. Based on the foregoing, I,

, agree that the NPGAA and its affiliate member programs and its employees, agents or representatives (the “NPGAA”) may release, as set forth in this Consent Form, information including, but not limited to, educational records otherwise protected from disclosure under FERPA, as follows:

1. Release of Educational and Sports Information I authorize the University to release information in any way related to my:

   • Eligibility to participate in intercollegiate athletics
   • Class schedule and class attendance
   • College in which enrolled
   • Health and injury status
   • Any other information pertinent to my educational or athletic needs
   • Eligibility for scholarship or financial aid
   • Grades (including semester or cumulative grade point average)
   • Physical ability to participate
   • Suspensions or dismissals from a team

   I authorize the release of this information to the following persons, agencies, and entities:

   • The National Collegiate Athletic Association (NCAA), National Association of Intercollegiate Athletics (NAIA), National Christian College Athletic Association (NCCAA), United States Specialty Sports Association (USSAA), National Junior College Athletic Association (NJCAA) or any other nationally recognized reputable collegiate or college-affiliated athletic association or their authorized representatives.
   • Authorized representative(s) of any team or group that has been, is, or will be in professional or amateur competition utilizing athletes who either attend the one of the college-affiliated athletic association or whose athletic eligibility has expired (including but not limited to national sport governing bodies, professional league representatives and/or player associations);
   • Federal or state agencies or other entities authorized to receive such information under FERPA.

2. Release of Sports Information I authorize the NPGAA to release my: photograph; birth date and place of birth; athletic statistics; and summary statements related to my class, college, eligibility status, medical ability to participate, health and injury status, any suspensions or dismissals from a NPGAA member team, I authorize the release of this information to the media, my parent(s) and/or legal guardian(s), and to the public through announcements, press releases, NPGAA publications or other reputable record books, statistical compilations, seasonal series or game programs or prospectuses.

3. The NPGAA may make releases about me orally, or by copy, extract, or summary statements, or in such other manner as required by NPGAA rules or the regulations of recognized and reputable associations of which the NPGAA is a member, including historical reports, statements of permissible financial aid and financial assistance, certificates of eligibility and scholarship, squad lists, and affidavits relative to participation or eligibility. I understand that the NPGAA has the option to release the above information and it may choose not to release some or all of that information at its sole discretion.