AWS - Physical Activity Modification Request Form 2020

Physical Activity Modification Request Form
Part 1: To Be Completed By The Parent
Student Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number
Format: (000) 000-0000.
Grade
Physician's Name

First NameLast Name
Phone Number
Format: (000) 000-0000.
Signature
Date

MonthDayYear
Date
Part 2: To Be Completed By The Physician
Medical diagnosis
Duration of Condition
The Condition is
Date student may return to unrestricted activity

MonthDayYear
Date
Date student will be reexamined

MonthDayYear
Date
Functional Capacity
Part 3: To Be Completed By The Physician

Check all activities that you consider to be appropriate for the student to participate in. Remember that all activities will be modified for student's ability level.
Locomotor Skills
Fitness:
Cardiovascular
Flexibility
Muscular Strength and Endurance
Dance Activities

Other
Individual Skills (non contact activities or individual practice skills)
Team Activities (game situations where contact with other students is likely to occur)
Tumbling and Gymnastics
Types of Games
Provide additional comments that will aid in the modification of physical activity for this student:
Physician Signature
Submitter's Email
example@example.com
Should be Empty:

Physical Activity Modification Request Form