Sample Return to Physical Activity Form (Non-Concussion Medical Illnesses/Injuries)
The Return to Physical Activity Form (Non-Concussion Medical Illnesses/Injuries) must be completed by parents/guardians and returned to the principal/designate for any student who has missed a physical education class due to an injury or illness requiring professional medical attention (for example, medical doctor, nurse practitioner, chiropractor, physiotherapist).
Name of Student:
Teacher:
Results of Medical Examination
As a result of my child’s/ward’s injury/illness, (insert injury/illness), medical attention by a (check one) [Medical doctor/Nurse practitioner/Other medical specialist] has been accessed with the following results (check appropriate box(es)):
No limiting features of the injury/illness have been observed and therefore he/she may resume full participation in physical activity with no restrictions.
Some features of the injury/illness remain which limit the ability to participate without restrictions. My child/ward may participate in physical activity following the accommodations to his/her physical activities listed below. (Accommodations must be provided prior to any physical activity taking place.)
A diagnosis that the injury/illness will prevent my son/daughter from participating in physical activity until further notice was received.
Refer to comments below and/or attached information.
Parent/Guardian signature:
Date:
Comments: