MEDICAL EXCUSE FORM FROM PHYSICAL EDUCATION

MEDICAL EXCUSE FORM FROM PHYSICAL EDUCATION
Date__________
Student Name_____________________________School_____________________Grade_____________
Physician: Our priority is the student’s health and safety while in school; therefore, your assistance in
providing us the specific information will help us provide the best care for this student. If you have any
questions, please feel free to contact me @______________________.
Thank You
_________________________________________
School Nurse
Medical Diagnosis: ___________________________________________________________
Type of Disability:
___Cardio-vascular
___Orthopedic
___Hearing impaired
___Visually impaired
___Muscular
___Neurological
___Pulmonary
___Other, specify_______________________
Status:
___Refrain from ALL Physical Education activities.
___No excuse indicated: Student should participate in Physical education
___Student may participate on a limited basis as indicated below.
___Student will require special protective equipment to participate in physical education
Specify equipment:____________________________________________________________
Condition is:
___Permanent for this school year
___Temporary, may resume normal activities,
Date: _____________________
Limitation of the following physical activities:
___Contact sports
___Aerobics
___Running
___Gymnastics
___Low impact sports
___Floor exercises
___Walking
___Other (please explain) ________________________________________________________
Physician’s Name _______________________________________Phone_________________
Physician’s Signature ____________________________________Date__________________
Revised 7/2015
Consent for Release of Medical Information
Name of Student: ____________________________________ DOB: __________________________
School: _____________________________________________Grade:__________________________
Parent /Guardian Authorization for School Staff to Communicate Health Information
I authorize the District’s designees, including District medical/counseling professionals, to share/obtain
my child’s health related information with the medical health professional or health care provider, for the
purpose of planning, implementing, or clarifying actions necessary in the administration of school related
health/counseling services such as but not limited to: emergency care, care for any documented diagnosis,
and medical treatments.
________________________________________
Parent/Guardian’s Signature
____________________________
Date
Autorización del padre /tutor para que el Personal Escolar Comunique los Datos Médicos
Autorizo a los representantes del Distrito, incluyendo los profesionales médicos del Distrito, a compartir
con el profesional médico o proveedor de salud para obtener los datos médicos de mi hijo/a para
planificar, implementar o clarificar acciones necesarias en la administración de servicios escolares
relacionados con la salud, que incluyen pero no se limitan a: atención de urgencia, cuidado para cualquier
diagnóstico, o tratamientos médicos.
_________________________________________________
______________________________
Firma de Padre/Tutor
Fecha
Revised 7/2015
Revised 7/2015