Fill and Sign the General Pre Participation Form Student Athlete Nutritional Supplement Disclosure and Review Form

___________________________________________ (Name of College or University) General Pre-Participation Form Student-Athlete Nutritional Supplement Disclosure and Review Form I, _____________________________________ (Printed Name of Student-Athlete) 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 substances 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. By making this disclosure, I am requesting that these products and their ingredients be reviewed by the ______________________________________ (Name of College or University) Head Athletic Trainer and Nutritional Consultant for the purposes of determining whether they are medically safe to use and do not contain substance banned by the NCAA. I understand that I should not take or use these products until their usage has been approved by the Head Athletic Trainer. Brand Name Listed Ingredients Banned Substances 1. ______________________ ____________________________ ______________________ 2. ______________________ ____________________________ ______________________ 3. ______________________ ____________________________ ______________________ 4. ______________________ ____________________________ ______________________ 5. ______________________ ____________________________ ______________________ Signatures: ___________________________________ ___________________________ Student-Athlete Date ___________________________________ ___________________________ Head Athletic Trainer Date Academic Year (e.g., 2007 -2008) __________________