Medical Excuse Form from Physical Education
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If a patient requests that they be excused from jury service for reasons related to mental or physical conditions, the law requires a written statement from a physician. In the absence of a physician, a professional caregiver may complete this form.
MEDICAL EXCUSE FORM
FROM PHYSICAL EDUCATION
FROM PHYSICAL EDUCATION
Date__________
Parents: Your kid has requested an excuse from physical education. In compliance with the State minimal standards regarding graduation demands and in accordance with the Board of Education policy, each student is compulsory to take Physical Education. A doctor’s note must be kept on file each year saying limitations and recommended physical education activities.
Student name_____________________________School_________________ Grade____
Doctor: For psychological as well as physical reasons, it is important that each student participate, so any limitations and suggestions will be appreciated.
Type of Disability:
___Cardio-vascular
___Visually impaired
___Muscular
___Orthopedic
___Neurological
___Pulmonary
___Hearing impaired
___Other, specify_______________________
Status:
___Refrain from ALL Physical Education activities.
___No excuse indicated: Student should participate in Physical Education class.
___Student may participate on a limited basis as indicated below.
Condition is:
___Permanent for this school year
___Temporary, may resume normal activities, (Date)_____________________
Limitation of the following physical activities:
___Contact sports
___Aeorbics
___Running
___Gymnastics
___Low impact sports
___Floor exercises
___Other (please explain)__________________________________________________________
Physician’s Name_______________________________________Phone_____________
Physician’s Signature____________________________________Date______________
Physical Education Teacher is to place this completed form in the student’s permanent record file.
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