Clark University | Athletics | Sports Medicine

Clark University

Clark University
950 Main Street • Worcester, MA 01610
Tel: 508-793-7711 •


	Athletics


	Sports Medicine Medical Clearance Forms For First-year Varsity Athletes Please send all three completed 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. Athletic Physical Examination Form (Submitted prior to first-year or transfer participation) - Clark’s athletic physical form (download below) stating clearance for sport activity must be completed/signed by a Doctor, Nurse Practitioner or Physician’s Assistant and submitted before the first-year of athletic participation. - The athletic physical examination must be performed within six months prior to the first team practice or try-out date of the first year of participation. - Page 2 of the form must have a parent signature acknowledging the University's Excess Athletic Insurance policy. - If the student-athlete submits a photocopy of Clark’s “Health Services Physical Examination Form” the physical exam must have been performed within six months prior to the first date of participation. In addition, Page 2 of the athletic physical form must be submitted acknowledging the University's Excess Athletic Insurance policy. Download Athletic Physical Examination Form (PDF, 2 pages) 2. 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) 3. 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.