Athletic Training
MEMO: Medical
Clearance for Athletic
Participation
TO: All WPI Varsity Student-Athletes and Parents
FROM: Michael DeSavage, Head Athletic Trainer
•
Welcome back…
•
Mandatory Participation Forms
- Can also be found at:
http://www.wpi.edu/Academics/Depts/PE/Forms/physicalform.pdf
- There are 5 components:
1. The Information and Medical History Form
2. The Pre-participation Physical
-Your physical must be performed by the appropriate medical professional (MD, DO, PA, NP)
3. The Insurance Acknowledgement Form
4. Copy of the front and back of your insurance card (unless you have School
Insurance or military insurance).
5. ADD/ADHD form if necessary
Mail or Fax to:
WPI
ATTN: Michael DeSavage
Athletic Training Department
100 Institute Road
Worcester MA, 01609
FAX#: 508-831-6185
AND/OR
ATTN: Michael DeSavage
Due Date -The physical must be dated prior to the start of your season and will expire on that
date annually.
The packet in its entirety needs to be received by the athletic training department prior
to the start of your season.
THE EARLIER THE BETTER.
If you have any questions regarding this information please contact: Mike
DeSavage at office# 508-831-5733 or email: athletictraining@wpi.edu.
Thank you for your cooperation.
Information and Medical History Form
Office use: Clear
Athletic Training
Sport:_____________ Last, First Name, MI: _______________________________________ DATE OF EXAM:_____________
Year of graduation:_____________ DOB:____/____/____ SOC#:____/_____/______
Home Address:_______________________________________________________________________________________________
Emergency contact number:__________________________ E Contact Name:__________________________
Athletes School/cell Phone#___________________________
E-Mail Address:_____________________________
Primary Care Physician____________________________ Phone#_______________________
Primary Medical Insurance:_______________________________ Insurance Phone#______________________
Policy Holder:___________________________________________ Policy Number:___________________________
MEDICAL HISTORY:
Do you have any allergies to drugs, foods, insects etc.?_______________________________________________________________
Do you suffer from asthma? ____________________________________________________________________________________
Are you currently taking any medications/supplements? ______________________________________________________________
Have you ever received a concussion? If yes, What severity and how many?______________________________________________ Have
you ever injured your neck or spine? Explain:__________________________________________________________________
Have you ever been hospitalized or under gone surgery of any type? (Include dates)________________________________________
Do you have a history of joint or muscle injuries? If yes, please explain?_________________________________________________ Have
you ever broken a bone? If yes in the last 5 years, describe and give dates._________________________________________
Have you ever suffered from heat exhaustion or heat stroke?___________________________________________________________
Have you ever had chest pain, shortness of breath or fatigue while exercising?____________________________________________
Have you ever been diagnosed with a heart murmur or high blood pressure?______________________________________________
Do you have any other health issues that would place you at risk of serious injury while participating in sports?__________________
Acceptance of Risk : WPI, in compliance with NCAA guidelines, reminds its student-athletes of the inherent risks of injury
during intercollegiate athletic participation. WPI, and its athletic administrators, coaches, and sports medicine staff, shares
these risks by endeavoring to create a safe environment for competition. For their part, student-athletes are strongly advised to
adhere to their coaches', athletic trainers', and associated physicians' health and safety instructions, including the rules of their
sport, while participating in contests, practices, training sessions, and travel to effectively reduce the risks of injury.
Athletes please read and sign below. Minors require parental signature.
Consent for treatment: I hereby give consent to the WPI Athletic Training staff and affiliates for routine medical treatment of minor injuries
or illnesses and in the event of an emergency permission to secure appropriate treatment for me including orders for emergency surgery
and anesthesia if necessary. Consent to Release: My signature below verifies the release of relevant medical information to the WPI
Athletic Training Staff and affiliates’ to include the team physician’s office and WPI Health Services. (This release may be rescinded upon
request).
Student signature
Signature of parent or guardian
Printed name of parent or guardian
Pre-Participation Physical Form
100 Institute Road Worcester, MA 01609
Athletic Training Department
Date of exam: _________ Name:_____________________________________ Sport:________________________________
HEIGHT:________ in. WEIGHT:________ lbs. BP:_________ PULSE:________ RESPIRATIONS:_________
ALLERGIES:___________________________________________________________________________________
NORMAL
NO. SYSTEM
.
.
Yes No List number of deformities and describe
1. Skin
________________________________
2. Eyes
________________________________
3. Ears
________________________________ 
4. Nose & throat ________________________________
5. Lymphatics ________________________________
6. Chest & lungs ________________________________
7. Acne
________________________________
8. Abdomen
________________________________
9. Hernia
________________________________
10. Genitalia
________________________________
11. Pelvic
________________________________
12. Rectal
________________________________
13. Orthopedics ________________________________
14. Neurological ________________________________
15. Psychological ________________________________
16. Cardiology Exam should include:
.
Precordial ausculations (supine and standing) to identify murmurs, specifically related to the left ventrical out flow
obstruction. Normal Abnormal Explain:__________________________________________
. Assess femoral artery pulses to rule out coactation. Normal  Abnormal  Explain below
. Assess for physical stigmata of Marfans Syndrome. Normal  Abnormal  Explain below
. Assess brachial artery blood pressure while sitting. Normal Abnormal  Explain below
17. I have known the applicant for ______________ years.
18. The applicant is in:  Excellent  Good  Poor Health.
19.
YES NO THE APPLICANT MAY PARTICIPATE IN SPORTS WITHOUT RESTRICTION
Do you have any recommendations for the care of this student?
The following abnormalities should be noted.
No  Yes Explain: _______________________________
The applicant: Has a loss of or seriously impaired function of an organ. Yes No 
Should not participate in sports due to: ____________________________________________________________________
___________________________________, M.D. ___________________________________________________________
Print name of physician
Signature
Explanations:
Physician Office Stamp
INSURANCE REQUIREMENT
ACKNOWLEDGEMENT
Subject: Student Insurance
From: Dana Harmon, Director of athletics
To: All Varsity student athletes
Please note per the NCAA, all student-athletes must provide evidence of insurance that includes coverage for
athletically-related injuries. This is a pre-requisite for practice and competition. No student will be allowed to
participate in any way until such evidence of current insurance coverage is on file with the WPI Department of
Athletics.
The enclosed Insurance Requirement Acknowledgement Form, a completed Information and Medical
History Form, a completed Pre-Participation Exam (physical) Form and a photocopy of both sides of your
current insurance card must be on file before a student can participate.
Your insurance coverage should have a limit of at least $75,000 and cover athletically-related injuries (no
exclusions). If you have questions regarding the terms of your coverage, you should contact your insurer
immediately. If your insurance does not cover athletically related injuries, you must purchase WPI’s student
insurance for your son or daughter to participate. Information can be found at www.wpi.edu, search term:
“student health insurance”.
If your insurance does cover athletically related injuries but has exclusions and/or is less than $75,000 in
coverage, please be aware that you are responsible for any and all expenses up to $75,000 unless you purchase
additional coverage on your own or through WPI’s student insurance.
WPI will assume no responsibility whatsoever for the payment of, or authorization to pay, medical or dental
expenses resulting from injuries that occur while participating in intercollegiate athletics at WPI.
For your information, the NCAA’s Catastrophic Injury Insurance Program covers student-athletes who are
catastrophically injured while participating in a covered intercollegiate athletic activity (subject to all policy
terms and conditions). The policy has a $75,000 deductible. This coverage does not qualify as the basic
coverage required for participation in athletics at WPI. It is supplemental coverage in the event of a
catastrophic injury. More information on this program can be found on the NCAA's web-site at www.ncaa.org.
If you have any questions regarding this requirement, please contact Mike DeSavage at 508-8315733.
This page does not need to be returned. It is provided for your information. This form must be signed by a parent,
guardian, legal representative or policy holder
INSURANCE REQUIREMENT ACKNOWLEDGEMENT
Acceptance of Risk: WPI, in compliance with NCAA guidelines, reminds its student-athletes of the inherent
risks of injury during intercollegiate athletic participation. WPI, and its athletic administrators, coaches, and
sports medicine staff, shares these risks by endeavoring to create a safe environment for competition. For their
part, student -athletes are strongly advised to adhere to their coaches', athletic trainers', and associated
physicians' health and safety instructions, including the rules of their sport, while participating in contests,
practices, training sessions, and travel to effectively reduce the risks of injury.
I, _________________________________, as parent, guardian or legal representative, attest that
(name, please print)
______________________________ has insurance coverage under a current, in force insurance
(student-
athlete name)
policy or policies for injuries that occur while he/she is participating in intercollegiate athletics. I am aware
that this coverage should be at least $75,000 and that I am responsible for any and all expenses up to
$75,000.
If there is a material change in coverage or expiration of coverage, I agree to notify WPI of this development
and update the insurance information I have on file with the WPI Athletic Department.
I understand and agree that WPI will assume no responsibility whatsoever for the payment of, or
authorization to pay, medical expenses resulting in injuries that occur while participating in intercollegiate
athletics at WPI.
(parent, guardian or legal representative signature)
(date)
The following need to be returned to the Athletic Training Office in order to be considered for
participation:
1) THIS INSURANCE ACKNOWLEDGEMENT FORM, SIGNED (BY PARENT, GAURDIAN OR LEGAL REPRESENATIVE)
2) COMPLETED AND SIGNED INFORMATION AND MEDICAL HISTORY FORM
3) COMPLETED PRE-PARTICIPATION PHYSICAL FORM WITH BOX 19 CHECKED OFF
4) COPY (FRONT AND BACK) OF YOUR CURRENT INSURANCE CARD
Adapted from the NCAA guidelines to document ADHD treatment with banned stimulant medications.
NCAA Banned Drugs and Medical Exceptions Policy
As of August 2009, the National Collegiate Athletic Association will be implementing a stricter application of the NCAA Medical
Exception policy, specifically for the use of the banned stimulant medications to treat Attention Deficit Hyperactivity Disorder (ADHD).
In order to apply for a medical exception for the use of ADHD medications, student-athletes will be required to submit additional
information regarding their medication use and assessments.
The student-athlete’s documentation from the prescribing physician to the sports medicine staff should contain a minimum of the
following information to help ensure that ADHD has been diagnosed and is being managed appropriately (see Attachment for physician
letter criteria):
a. Description of the evaluation process which identifies the assessment tools and procedures.
b. Statement of the Diagnosis, including when it was confirmed.
c. History of ADHD treatment (previous/ongoing).
d. Statement that a non-banned ADHD alternative has been considered if a stimulant is currently prescribed.
e. Statement regarding follow-up and monitoring visits.
Criteria for letter from prescribing Physician to provide documentation to the Sports Medicine staff regarding assessment of studentathletes taking prescribed stimulants for Attention Deficit Hyperactivity Disorder (ADHD), in support of an NCAA Medical Exception
request for the use of a banned substance.
The following must be included in supporting documentation:
Student-athlete name.
Student-athlete date of birth.
Date of clinical evaluation.
Clinical evaluation components including:
o Summary of comprehensive clinical evaluation (referencing DSM-IV criteria) – attach supporting documentation.
o ADHD Rating Scale(s) (e.g., Connors, ASRS, CAARS) scores and report summary – attach supporting documentation.
o Blood pressure and pulse readings and comments.
o Note that alternative non-banned medications have been considered, and comments.
o Diagnosis.
o Medication(s) and dosage.
o Follow-up orders.
Additional ADHD evaluation components if available:
Report ADHD symptoms by other significant individual(s).
Psychological testing results.
Physical exam date and results.
Laboratory/testing results.
Summary of previous ADHD diagnosis.
Other comments.
Documentation from prescribing physician must also include the following:
Physician name (Printed)
Office address and contact information.
Specialty.
Physician signature and date.
ADHD/ADD MEDICATION EXCEPTION
Sport: ________
Name (Last, First, M.I.):________________________________
Home address: ___________________________________________________________
Year of graduation: ______
DOB: ___/___/___
Blood pressure: ________________
Date of clinical exam: ____/____/_____
Pulse: ___________________
Diagnosis: __________________________________
Date confirmed: ____/____/______
Medication & dosage: ___________________________________________________________________
Follow-up & monitoring visits occur (yearly, monthly, etc.): _____________________________________
Treatment history (previous & ongoing): ____________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
________________________________________
Alternative non-banned ADHD medications considered: _______________________________________
_____________________________________________________________________________________
Please describe eval process and assessment tools/procedures: _________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
________________________________________
ADHD rating scale used & score: __________________________________________________________
Report summary: ______________________________________________________________________
_______________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
_____________________________________________
*Please attach supporting documentation for the clinical evaluation and the rating score report.*
*Please attach a copy of the current prescription.*
____________________________
Physician’s printed name
__________________________________
Physician’s signature
Physician Office Stamp:
Specialty: ___________________________________
_____________
Date