MEDICAL EXCUSE FORM FROM PHYSICAL EDUCATION
Transcripción
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