NEW JERSEY STATE INTERSCHOLASTIC ATHLETIC ASSOCIATION
1161 Route 130 North, Robbinsville, NJ 08691-1104
STUDENT-ATHLETE RESIDENCY AFFIDAVIT
EC Approved 4/1/20
Print Student’s Full Name
School
Date
I, ______________________________________________________, of full age, being duly sworn to law, upon my oath
depose and say:
1. I am the parent/legal guardian of the above listed student. (circle)
2. I currently reside at: ___________________________________________________________________________
I have resided at the above address since: _________________________________________________________
3. The above-named student moved with me at my new address on: _______________________________________
4. Prior to moving to the new residence address listed above, I resided at the following address:
______________________________________________________________________________________________________________________________
5. Prior to moving to the new address listed in #2 above, the student resided at the following address:
___________________________________________________________________________________________
with named parent/legal guardian_______________________________________________________________
6. I hereby authorize the New Jersey State Interscholastic Athletic Association (“NJSIAA”) to investigate and
confirm any and all Statements made by me in this affidavit. I agree to provide any additional information that
may be requested by the NJSIAA.
7. I will notify the present school immediately, in writing, if any of the conditions recited herein are changed.
8. This residence may not be associated with, leased, or provided by anyone associated with the school or acting at
the direction of the school, including but not limited to administration, staff, coaches, students, parents, booster
clubs, or any organization having a connection with the school.
I hereby certify that the forgoing statements are true, and I am aware that if any of the foregoing statements are
willfully false, I am subject to punishment.
Parent/Guardian Signature
Print Parent/Guardian Full Name
STATE OF NEW JERSEY, COUNTY OF ______________________________. The above-named affiant appeared before me, a
notary public of the State of New Jersey, on the __________day of ____________________, 20__________ and I made known to
him/her the contents of the above affidavit which was then sworn and subscribed to by said affiant before me on this date.
Notary Public: ______________________________________________
Copies of this Affidavit must be sent to the New Jersey State Interscholastic Athletic Association upon request
