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Chelan Middle/High School
Physical Education Department
Chris
Griffiths, Joe Harris, Bill Sargent
CHS 682-4061 ext 123 (girls) ext
122. (boys) Email: last name. first
initial@
chelanschools.org
TO: PARENTS AND GUARDIANS OF CHELAN MIDDLE/HIGH SCHOOL STUDENTS
RE: A NOTICE ABOUT PHYSICAL EDUCATION CLASSES
If your son/daughter is to have limited physical education due to injury or illness, please have your doctor fill out this form. Additional forms may be obtained from the physical education teacher, school nurse or the school office.
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Dear Physician:
State education law requires that all students be enrolled in a physical education course. The physical education program at Chelan Middle/High School is planned so that every student who is able to be in school will be able to benefit from some phase of the physical education program. Since we as professionals want to do what is best for each and every child, we will attempt to modify our physical education activities/schedule to meet the specific limitations of the student listed below. With these thoughts in mind, we would like you as the attending physician to recommend for the student listed below the extent of activity in which he/she may participate.
Please complete the information on the back of this form as requested and check the activities in which the student may safely participate considering his/her injury or illness. We will develop a program of activity based on your recommendations. Thank you for your time, assistance and consideration.
Sincerely,
Chelan Middle/High School Physical Education Department
******Please
complete, sign and return the back page to: Chelan Middle/High School Physical
Education Department******
Please complete, sign and return to
Chelan Middle/High School Physical Education Department
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NAME OF STUDENT/PATIENT ___________________________________________
DATE OF OFFICE VISIT___________
INJURY/ILLNESS_______________________________________________________
***** LIST SPECIFIC INSTRUCTIONS REGARDING PARTICIPATION:
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
LIMITED PARTICIPATION
COVERS DATES FROM ___________TO ___________
**** If participation is limited due to acute illness or injury a release from
the attending physician will be required before student is allowed to return
to full participation in class.
ACTIVITIES PERMITTED
ALL YEAR ALTERNATIVE ACTIVITIES:
_____ Recumbent Bicycle (upper, lower body or both)
_____ Treadmill
_____ Pace Walking
_____ Step Machine
_____ Weight Training (upper, lower body or both)
_____ Jogging