Reinstatement from Medical Withdrawal - Part II
840 Wood Street
Clarion, PA 16214
Part II: Reinstatement Certification
I am requesting to return to Clarion University for the semester/year. I give my
full consent to allow the Provost’s Office to contact the licensed healthcare professional outside the University
Student Signature Date
student above has been cleared medically and has completed recommended actions. I certify that the
student is medically able to attend Clarion University for the
appropriate documentation is attached.
Comments or restrictions:
Name, Title, State and License # of healthcare professional (M.D. or D.O.) recommending medical reinstatement
Signature Email Phone Date
DO NOT WRITE BELOW THIS LINE – OFFICAL USE ONLY
Approved to Return (Hold Removed) Not Approved to Return
Provost's Signature Date
Documentation must be appended to this form in order to effect the medical withdrawal or reinstatement.
A copy of the form, Part I, should go to the student. The original stays with the Registrar’s Office. Once a
student comes back, s/he should take a copy to the licensed healthcare professional, M.D. or D.O to be
cleared (Part II). Again, a copy is given to the student, and the original stays in the Registrar’s office.
Revised for use 9/2018