Referral of Varsity Athlete

to

University Medical Center

Complete and return to the athletic trainer:

_______________________________________ has symptoms related to

Sport: __________________________________ Athletic trainer: ________________________________

Phone extension: __________________________

Physicianís diagnosis:

Recommendation for practice:ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ _____ Full

ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ _____ LimitedÝÝÝÝÝÝÝÝÝÝÝÝÝ ______ Days

ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ _____ None forÝÝÝÝÝÝÝÝÝÝ ______ Days

________________________________ÝÝÝÝÝÝÝ ________________

Physician SignatureÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ Date

The NCAA does not permit the athletic department to pay for the care of illness.