Aurora University Department of Athletics
Student-Athlete Dietary Supplement/Medication Disclosure & Review Form
Appendix C
I,_______________________________________ (Student-Athlete Name) am taking or intend to take the following dietary supplement(s) and/or medication(s). I acknowledge the risk of losing my eligibility to participate in intercollegiate athletics if I test positive for an NCAA or Aurora University banned substance that may be found in any substance that I take, regardless of the reason or purpose for taking such supplement(s) or medication.
I acknowledge and understand that the labeling on these products can be misleading and inaccurate, and that sales personnel are neither motivated nor qualified to accurately certify that these products contain no banned substances. “Healthy” or “naturally occurring” are terms often used to market sales of dietary supplements, but do not necessarily mean they are safe.
Before taking or using any dietary supplement or medication, I am responsible for ensuring the product does not contain any banned substance. By making this disclosure, I am requesting that these products and their ingredients be reviewed by Aurora University’s sports medicine staff for the purposes of determining whether they are medically safe to use and do not contain banned substances. I understand that I should not take or use these products until their usage has been reviewed by Aurora University’s sports medicine staff.
Medication/Brand Name: Listed Ingredients:
(Athletic Trainer to review, circle banned substances and notify student-athlete.)
1.____________________________________ _______________________________________
_______________________________________
_______________________________________
_______________________________________
2.____________________________________ _______________________________________
_______________________________________
_______________________________________
_______________________________________
3.____________________________________ _______________________________________
_______________________________________
_______________________________________
_______________________________________
4.____________________________________ _______________________________________
Signatures:
_________________________________________________ _________________________________________________
Student-Athlete Signature Date Athletic Trainer Signature Date
