Background: Sudden cardiac death in a young athlete is a catastrophic event with an incidence of approximately 1:40,000 to 1:80,000. Pre-participation sports screening in adolescents and young adults utilizes a history, physical, and 14-point targeted questionnaire. Countries such as Italy and Japan have added electrocardiogram (EKG) screening programs, however, in the USA no national mandate exists. The reasons for this include concerns for the constraints on the healthcare system, manpower, cost, access to follow-up care, and false-positive results. Recently, some states and local municipalities have implemented pre-participation EKG screenings. Methods: In 2019, a central Florida County School Board adopted a policy requiring an EKG in addition to the traditional history and physical for pre-sports participation for middle and high school competitive sports. Families have an option to opt- out. The school district partnered with a non-profit group that provides low-cost EKGs. Students were able to use an online program to schedule their screening. EKGs were performed at each middle and high school within the county for a $20.00 fee, which was waived for those who could not afford the expense. Volunteer pediatric cardiologists interpreted the results. The results were emailed to all parents or guardians. Students with abnormal results received a phone call to ensure follow- up care was arranged and for self-reporting of the final diagnosis. For those without financial means, a local free medical clinic was utilized for follow-up. Results: The central Florida county school system had more than 30,000 students enrolled in middle and high schools in 2019. There were 5,877 EKG screenings between 4/1/19 and 12/31/19. The results included 3% abnormal EKGs (199/5,877). Of the 199 abnormal readings: 27% had conduction delays (54/199), 26% arrhythmias (51/199), 13% ventricular hypertrophy (25/199), 11% had ST or T-wave abnormalities (21/199), 8% had prolongation of the QTc interval (16/199), 6% Wolff-Parkinson-White syndrome (12/199), and 4% had axis deviation (7/199). Self-reported follow-up results were available for 56% (112/199). In those self-reports, the incidence of critical heart disease that had a risk of sudden cardiac arrest was .14% (8/5,877): 6 who underwent an ablation procedure for Wolff-Parkinson-White syndrome, 1 with gene positive long QTc and one with left ventricular hypertrophy who is undergoing genetic evaluation for hypertrophic cardiomyopathy. Conclusions: To our knowledge, this is the first large school district in Florida to mandate this level of cardiovascular screening. This pilot project demonstrated that a large volume EKG screening is feasible with appropriate manpower, at a low-cost, with access to follow up-care. This model may allow broader use of EKG as a screening tool if combined with a skilled clinician infrastructure to ensure accurate EKG interpretation for statewide or national EKG screening in adolescents prior to athletic participation.