Return To School/physical Education/sport Form
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1RETURN TO SCHOOL/PHYSICAL EDUCATION/SPORT FORM
RETURN TO SCHOOL STATEMENT
MODIFIED ACTIVITY
(Check all that apply)
May return to school on ____________
No contact sports
Next appointment: ________________
No strenuous sports
ACTIVITIES RECOMMENDED AT SCHOOL
No running/jumping
No restriction of activity
No weightlifting
No PE/sports for (#) _________weeks
No upper arm/overhead
May participate in gym, but not competitive sports
Biking/treadmill/elliptical OK
May resume PE/sports in (#) ______weeks
ADDITIONAL RESTRICTIONS:
May climb stairs with crutches
_______________________________________
_______________________________________
Needs assistance between classes
_______________________________________
Needs to pass early
COMMENTS: ___________________________
_______________________________________
Wear a supportive tennis shoe
_______________________________________
_______________________________________
May work with certified Athletic Trainer
Equipment:
PHYSICIAN INFORMATION
Physician’s Signature:
Crutches
_______________________________________
Braces
Physician’s Name:
Cast
_______________________________________
Walking (CAM) boot
Other: ______________________
Phone: _________________________________
# of weeks _________________________
Fax: ___________________________________
P
E
D
HYSICAL
DUCATION
EPARTMENT
M
E
P
EDICAL
XCUSE
OLICY
To earn credit in Physical Education courses, the curriculum requires students to participate in physical activity. Students
with valid doctor’s medical excuses that inhibit full activity for two or more units may be removed from their Physical
Education class and placed in a study hall for the remainder of the semester. These students will make up the missed units
in the following semester. In some cases, adjustments to the Physical Education curriculum may be possible, thus allowing
the student to remain in their Physical Education class. The student’s limitations must be outlined, in detail, by the physician,
on the Medical Return to School form.
Note: This form, applies to Physical Education courses, interscholastic sports, and co-curricular activities where there is
physical activity.
2130 W. Roosevelt Road Wheaton, Illinois 60187‐6029
(630) 668‐5800 Fax (630) 668‐5893
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Parent category: Medical