OFFICIAL NAIA HARDSHIP REQUEST CERTIFICATE



NAIA Official Hardship Request Certificate

A hardship request is a request for an exception to the season of competition regulation (NAIA Bylaws Article V, Section B, Item 18). All hardship requests must be referred to the NAIA National Office, Attn: Legislative Services. The student’s current transcript MUST be submitted with the request.

|Case # (for national Office use Only) | |

|1. |Name of Athlete: |      |Sport in Question: |      |

| |Submitting Institution: |      |Conference: |      |

| |Address: |      |

|2. | | | |

| |Date of injury or illness which incapacitated the student: |      | |

| |incapacitated the student: | | |

| | | | |

|3. |List the institution’s name the student played for, all date(s), and all opponent(s) (institutions) the student competed against for the year in |

| |question. Scrimmages are not counted against the maximum allowable contests for hardships, but should be listed and noted as scrimmages. |

| |Institution Where Athlete Competed: |      | |

|Date | |Opponent(s) | |Date | |Opponent(s) |

|      | |      | |      | |      |

|      | |      | |      | |      |

|      | |      | |      | |      |

|      | |      | |      | |      |

List all seasons of competition, including current season, of the sport in question. (Example: 2006-07, 2007-08)

|      | |      | |      | |      |

|4. |I hereby certify that the above information is complete and accurate: |

| | | |      | |      |

| |Athletics Director or Faculty Athletics Representative | |Position | |Date |

| | | | |

| |Coach | | |

|5. |To be completed in full by the attending physician (must be an M.D. or D.O.) |

| |please Check your answers and INITIAL each blank. |

| |1. Was the athlete under medical care prior to the injury or illness that | | YES NO NO |Initials       |

| |initiated this hardship request? | | | |

| |If yes, was the athlete medically released for participation prior to the | |YES NO | |

| |injury/illness in question? | | | |

| |2. Did the injury/illness incapacitate the student from competing the | | YES NO NO |Initials       |

| |remainder of the sport season in question? | | | |

| |3. When did you examine the athlete AND recommend no further competition | |Date ____/_____/____ |Initials       |

| |for the remainder of the season? | | | |

| |4. When, in your judgment, will the athlete be medically fit to return to | |Date ____/_____/____ |Initials       |

| |competitive athletics? | | | |

|5. | | | | | M.D. D.O. |

| Physician's Signature | |Date | |Physician's Printed Name |

| | | | | |

| | | | | |

|6. | | | | |

| Address City State, Zip | | | | |

|6. | Attach current transcript. |Send this form and transcript to: NAIA National Office, Attn: Legislative Services |

| | |All 6 areas of this form must be completed before the request can be considered by the |

| | |National Office, Legislative Services Dept. |

|FOR OFFICIAL USE ONLY — DO NOT WRITE IN THIS SPACE |

| |Granted | | | |

| |Denied. The request does not meet criteria established by membership. |NAIA Legislative Services Dept. | |Date |

| | | | | |

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