NCAA Buckley Statement for Waiver Requests Form

NCAA Buckley Statement for Waiver Requests

Statement to be signed by student-athlete and submitted with a request for waiver.
Buckley Statement. I give my consent to disclose to authorized representatives of this institution, its athletics conference (if any) and the NCAA any documents or information pertaining to my NCAA eligibility. Additionally, I give my consent to the NCAA to disclose my name and personally identifiable information from my education records to a third party (including but not limited to the media) as necessary to explain the NCAA's decision regarding this waiver request without such disclosure constituting a violation of my rights under the Family Educational Rights and Privacy Act.

Form Submission
STUDENT-ATHLETE VERIFICATION*

I certify that the information provided above is accurate and truthful. I have read the rules summary included in this form. I understand that providing misleading or false information will result in the loss of my intercollegiate eligibility.
STUDENT-ATHLETE SIGNATURE

By entering my University of Tennessee Student ID in the box, I indicate my understanding of the information shown and provided on this form, and it is my intent to be signing the record. I certify that my answers are complete and correct and that any fraudulent information may make me ineligible for intercollegiate athletic competition and or athletically related financial aid at University of Tennessee. I understand that University of Tennessee may share this information with the NCAA and that a photocopy of this authorization shall be as valid as an original.

State Law Requirement State law requires that you be informed of the following: (1) your consent is limited to this one transaction; (2) you are entitled to a paper copy of the documents you have signed; and (3) you are entitled to withdraw your consent to future electronic signatures.
Student-Athlete Name*

First NameLast Name
Student-Athlete E-mail*
Sport*
UT Student ID Number:*
Date Signed*

MonthDayYear
If you have questions about this form please call the Compliance Office at 865-974-3871.
Should be Empty:

NCAA Buckley Statement for Waiver Requests