Adapted Kinesiology - Medical Release Form
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1Adapted Kinesiology – Medical Release Form
Student Name: _______________________________
Physician Name (
): ___________________________
Phone # (
) ___________________
Required
Required
Please print
This letter is provided to inform you that the above named student has enrolled in an Adapted Activity course
(aquatics, resistance training, or sports) at Santa Ana College. In order for the instructor to develop a safe and
appropriate individual exercise program (IEP), we are requesting:
An examination of this student to determine their ability to engage in physical activity.
A case history indicating conditions and limitations of the student.
Physician recommendations and contra-indications.
All information provided here will be held in strict confidence.
Sincerely, Brian Sos, Ph.D. _________________________________
Date: __________________
Shaded areas to be filled in by a Physician (
):
Physician Area
Diagnosis / Medical Condition(s) which may be affected by exercise: ___________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Physical Limitations: _________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Contra-indications for exercise: ________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Physician’s signature (
): ____________________________________ Date: _______________
Required
Student Release Statement: I hereby authorize the release of any relevant medical records to Dr. Brian Sos and
the Disabled Student Services Program at Santa Ana College.
Student Signature: ________________________________________
Date: ________________
Please return this form to Dr. Brian Sos, Santa Ana College, DSPS Main Office, Russell Hall – R 101
Santa Ana, CA 92706
Original (
) = Instructor’s copy
Copy (
) = Physician’s copy
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