Lakeview Physical Education
Illness/Injury Form
Student
Name: Dates
of Restriction*:
Description
of Illness/Injury:
Please
let me know all the things the student CAN DO. (Check
all that apply).
|
Cardiovascular |
Muscular Strength/Endurance |
Flexibility |
Non Physical |
|
o
Bikes o
Treadmill o
Walking Only |
Upper Body o
Push Ups o
Dips/Pull Ups o
Sit Ups/Abdominals Lower Body o
Leg Work |
o
Upper Body Stretching o
Lower Body Stretching |
o
Team Building/Problem
Solving o
Fitness Knowledge |
Parent
Signature: Phone:
*
Restrictions lasting more than 3 days must have a doctors note attached to this
completed form.
Lakeview Physical Education
Illness/Injury Form
Student
Name: Dates
of Restriction*:
Description
of Illness/Injury:
Please
let me know all the things the student CAN DO. (Check
all that apply).
|
Cardiovascular |
Muscular Strength/Endurance |
Flexibility |
Non Physical |
|
o
Bikes o
Treadmill o
Walking Only |
Upper Body o
Push Ups o
Dips/Pull Ups o
Sit Ups/Abdominals Lower Body o
Leg Work |
o
Upper Body Stretching o
Lower Body Stretching |
o
Team Building/Problem
Solving o
Fitness Knowledge |
Parent
Signature: Phone:
*
Restrictions lasting more than 3 days must have a doctors note attached to this
completed form.