Health Form

Fields marked with an * are required

Student Information

Student Email Address *

First Name *

Middle Name

Last Name *

Birthdate *

Mailing Address *

Country

Street

City

Region

Postal Code

Student Cell Phone *

Gender

Student Type

Student Term*

Emergency Contact Information

Please list your emergency contact(s). This data will be used to provide contact information in the event of an emergency. Please list the contacts in the order you want them to be notified if an emergency arises. Clarke University will call those in the order listed until a person is reached.

Relationship *

First Name *

Last Name *

Phone *

Email Address *

Should this person be contacted in the event of an emergency? *

Yes

Add another emergency contact? *

Yes

Relationship *

First Name *

Last Name *

Phone *

Email Address *

Should this person be contacted in the event of an emergency? *

Yes

Add another parent/guardian? *

Yes

Relationship *

First Name *

Last Name *

Phone *

Email Address *

Should this person be contacted in the event of an emergency? *

Yes

Health Form

All student athletes must have a current physical dated after June 1 of the current academic year. The form is located at clarke.edu/studentathlete/forms.