2025-2026 Varsity Student Athlete Medical Clearance Form

To be medically cleared for intercollegiate (varsity) sports participation, all incoming first year and new students joining a varsity team are required to have a physical examination within 6 months of the first day of participation for their sport and upload a completed copy the physical examination form.

In addition to the physical examination form, all students must upload a completed Sickle Cell Trait Status form.

For both forms, a physician, physician assistant, registered nurse, or nurse practitioner who is not the student or a relative of the student must complete all questions in English and sign the forms.

Please do not submit this form until you have completed both forms and are prepared to upload them.

Student MIT ID Number

First_Name

Last_Name

DOB

mm/dd/yyyy

Phone Number

Please enter the best phone number to reach you with questions.

Phone

Varsity Sport(s)

Please select all sports in which you plan to participate.

Date of Physical Exam

Please enter the date you had your physical examination by a health care provider. This may be different than the date your provider signed your form.

mm/dd/yyyy

Date of Sickle Cell Test

Please enter the date of your sickle cell test.

mm/dd/yyyy

Sickle Cell Test Result

Negative

Positive

Pending Result

Need to be Tested

File Upload

Please upload your competed Varsity Student Athlete Physical Examination Form, your completed Sickle Cell Trait Status form and any additional documentation that will assist in your clearance process.

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