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 ____________________________________________