Please make sure ALL blanks are complete. If you check YES on any of the medical history questions, please explain on the back of the form. Please read the ECG statement carefully. A check in this box means you be getting your son/daughter a ECG. 

This form must be completed and signed by a student’s treating physician or other appropriate healthcare professional (MD/DO/APRN/PAC). In accordance with UIL Risk Mitigation Policies, this signed form must be on file with the Athletic Trainer in order to begin and/or complete clearance to return from COVID-19.