Physicians Recommendation For Pe Or Sports Participation printable pdf download

STUDENT NAME _________________________ DOB _______ SCHOOL ___________ GRADE _____

TO THE PHYSICIAN: If this student is unable to participate in a full physical education program, please

indicate the appropriate activity levels below.

VIGOROUS: Activities involving all-out effort to develop cardiovascular endurance, muscular strength, and

fitness. Check all appropriate levels:

_____ Collision: football, rugby, hockey, etc.

_____ Contact: basketball, baseball, soccer, wrestling, etc.

_____ Non-contact: cross country, swimming, track, tennis, etc.

_____ Other: bowling, golf, archery, field events, etc.

MODIFIED: Activities for students who are unable to participate in the full program, who need concentration

on a particular activity, or who need protective gear or preparation for participation.

_____ PROTECTIVE GEAR OR PREPARATION is needed for participation (e.g., protective

eyewear, knee brace for running activities, inhaler prior to vigorous activities, etc.).

_____________________________________________________________________________

_____ ACTIVITIES TO BE AVOIDED (e.g., running, throwing, jumping, exposure to cold air

below 40 degrees F.) Be specific:

______________________________________________________________________________

_____ ACTIVITIES TO BE ENCOURAGED (e.g., endurance activities such as fast walking,

running, or swimming; flexibility activities such as …, etc.) Be specific:

______________________________________________________________________________

_____ INDIVIDUAL PHYSICAL EDUCATION PLAN must be developed (e.g., ROM for

upper arms, breathing exercises for COLD or COPD students, etc.).

_____ Prescribed plan attached

_____ Contact physician’s office for guidelines

The above modification(s) need to be in effect for the following dates:

____________________ Beginning date

____________________ Ending Date

____________________ Re-evaluation needed before release or participation.

I certify that this student is under my continuing care, which will include monitoring the student’s continuing

need for services prescribed and/or for modification of his/her physical education program.

Physician Signature__________________________________ Print Name_________________________

Date________ Office Number ________________________ Fax Number _________________________

Address_______________________________________________________________________________

Parent Signature __________________________________________ Date _________

Physicians Recommendation For Pe Or Sports Participation