Physician'S Certificate Of Incapacitation-For Adaptive Or Exemption From Physical Education Form printable pdf download

Physician'S Certificate Of Incapacitation-For Adaptive Or Exemption From Physical Education Form

GENERAL McLANE SCHOOL DISTRICT

PHYSICIAN’S CERTIFICATE OF INCAPACITATION

FOR ADAPTIVE OR EXEMPTION FROM PHYSICAL EDUCATION

STUDENT’S NAME ____________________________________________________________

1. Nature of illness which renders the student unable to participate in regular physical education

and/or speciﬁc activities (incapacitated):

____________________________________________________________________________

______________________________________________________________________________

2. Speciﬁc period of time during which the following recommendations are to be in effect:

Incapacitated from: _______________________

_______________________

Month/ Day/Year

Month/Day/Year

3. I recommend that the General McLane School District provide an adaptive physical education

program to the above named student.

A. Permissible Activities:

1._____ low impact activity

2._____ moderate impact activity

3. _____ walking program/stationary bike

4. _____ stair climbing

5. _____ weight lifting

a. ____upper body

b. ____lower body

6._____ non contact activity (archery, tennis, golf, bowling)

B. _____ Increase activity as student feels able

C. _____ No physical activity of any kind

__________________________ ________________________

_____________

Signature of Physician

Printed Physician Name

Date

FAX completed form to: 273-1035 GM High School

273-1038 JWParker Middle School

273-1050 McKean Elementary 273-1040 Edinboro Elementary

Physician'S Certificate Of Incapacitation-For Adaptive Or Exemption From Physical Education Form