View Existing Entries Illness Return to Play Form Illness Return to Play Form Admin Use Only <p style="text-align: center;"><strong><span style="color: #ff0000;">ILLNESS</span> RETURN TO PLAY FORM</strong> <strong>Medical Clearance Releasing the Student-Athlete to Resume Full Participation in Athletics After an Illness</strong></p> Before the student-athlete will be allowed to resume full participation in athletics, this form must be signed by one of the following Licensed Health Care Providers: Licensed Physician (MD/DO), Licensed Physician Assistant (PA), Licensed Nurse Practitioner (NP) and the student-athlete’s parent/legal custodian. Athlete Illness Information Organization/School * Name of Student-Athlete * Name of Student-Athlete First First Last Last Diagnosis * Date of Diagnosis * Date Symptom Resolved * Printed Name of Medical Practitioner Printed Name of Medical Practitioner First First Last Last Job Title * Licensed Physician Licensed Physician Assistant Licensed Nurse Practitioner Signature of Medical Practitioner * Clear Parent/Legal Custodian Consent Date * <p style="text-align: center;"><strong>Parent/Legal Custodian Consent</strong></p> <ul> <li style="text-align: left;">I am aware that the North Carolina High School Athletic Association <strong>REQUIRES</strong> that student-athletes absent from athletic practice for five (5) or more consecutive days due to illness receive a medical release by either a physician licensed to practice medicine or his/her designee (licensed nurse practitioner, or licensed physician’s assistant) before readmittance to practice or contests.</li> <li style="text-align: left;">I acknowledge that the Licensed Health Care Provider listed above has provided medical care to my student-athlete.</li> <li style="text-align: left;">I acknowledge that the Licensed Health Care Provider listed above has released my student-athlete to resume full participation in athletics. By signing below, I hereby give my consent for my child to resume full participation in athletics.</li> </ul> By signing below, I hereby give my consent for my child to resume full participation in athletics. Printed Name of Parent/Legal Custodian * Printed Name of Parent/Legal Custodian First First Last Last Parent/Guardian Email Signature of Parent/Legal Custodian * Clear If you are human, leave this field blank. Submit Δ
