Doctor'S Restriction Form

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Del Campo High School PE Activity Requirements 
Doctor’s Restriction Form 
 
Full Restriction  (Please check all that apply) 
 
Modifications 
 
Jumping 
 
 
 
o High Knees/Butt‐kickers  _ ________________________________________________ 
 
o Jump Rope/Jumping Jacks_________________________________________________ 
o Box Jumps 
 
_________________________________________________ 
Cardiovascular   
 
 
o Running 
 
_________________________________________________ 
o Walking 
 
_________________________________________________ 
 
Strength 
 
 
 
o Crunches 
 
_________________________________________________ 
o Bicycles   
 
_________________________________________________ 
o Pushups 
 
_________________________________________________ 
o Pullups   
 
_________________________________________________ 
o Situps   
 
_________________________________________________ 
o Back Extensions   
_________________________________________________ 
o Walking Lunges  
_________________________________________________ 
o Air Squats 
 
_________________________________________________ 
 
Sport‐related   
 
 
o Basketball 
 
_________________________________________________ 
o Volleyball 
 
_________________________________________________ 
o Touch Football   
_________________________________________________ 
o Ultimate Frisbee 
_________________________________________________ 
 
o Soccer   
 
_________________________________________________ 
o Softball  
 
_________________________________________________ 
o Tennis   
 
_________________________________________________ 
o Golf 
 
 
_________________________________________________ 
o Badminton/Ping Pong  _________________________________________________ 
o Wrestling 
 
_________________________________________________ 
o Dance   
 
_________________________________________________ 
o Swim   
 
_________________________________________________ 
o Gymnastics 
 
_________________________________________________ 
 
Restrictions are:            Permanent  
 
     Until _____________ 
 
 
 
 
 
 
            
      
Initial End Date   
 
        
Doctor’s Name _____________________________________________ 
 
Doctor’s Signature ________________________________ Email _____________________________ 
 
Date ____________________________________________ 

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