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Sports Medicine

Medical Clearance Forms For Returning Varsity Athletes


Please send both complete forms to:
Sports Medicine Office
Clark University
Kneller Athletic Center
950 Main Street
Worcester, MA 01610

View the Sports Medicine Home Page

REQUIRED FORMS TO BE SUBMITTED:



1. Annual Student-Athlete Health Questionnaire

(Submitted annually)

- A completed medical questionnaire is to be handed in on an annual basis to be eligible for varsity athletics.
- Included on this form is a HIPAA authorization which also needs to be signed annually by the student-athlete.
-Athletes Blood Pressure and Pulse are taken and documented on this form. These readings must be within the normal range for athletic clearance.
Download Annual Student-Athlete Health Questionnaire (PDF, 2 pages)


2. Insurance/Emergency Contact Information

(Submitted annually)

- Updated Primary Insurance and Emergency Contact information must be submitted prior to clearance.
- Included on this form is the University's Excess Athletic Insurance Policy which also needs to be signed annually by the student-athlete.
Download Insurance and Emergency Contact Information Form (PDF, 1 page)

Summer Injury/Illness Documentation

(Submitted as needed)

-If a student-athlete suffers an injury or illness over the summer months that required a doctor's visit, he/she needs to submit a documented clearance note from the treating physician's office before being cleared for the upcoming season.
-The Sports Medicine staff can facilitate the student-athlete being seen by a physician at the University of Massachusetts Sports Medicine Clinic.
-Athlete will not be cleared until documentation of medical clearance to participate in sports is received by the sports medicine staff.

REASONS WHY ATHLETES MAY NOT BE CLEARED:

 - All forms are not signed, completed, and reviewed by the sports medicine staff
- Documentation of recent summer injuries or illnesses are not submitted
- Blood Pressure or Pulse is outside of normal ranges after three separate checks
- If the freshman physical examination form is a form other than the Clark University Athletic Physical Exam form which includes parent signature on the back, another form (page 2 of Athletic Physical Exam form) must be signed by a parent and submitted before the athlete will be cleared.