TO: PARENTS AND GUARDIANS OF STILWELL JUNIOR 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.

* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *

Dear Physician:

State education law requires that all students be enrolled in a physical education course. The physical education program at Stilwell 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 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,

Stilwell Physical Education Department

* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *

NAME OF STUDENT/PATIENT ___________________________________________

DATE OF OFFICE VISIT___________

INJURY/ILLNESS_______________________________________________________

SPECIFIC INSTRUCTIONS REGARDING PARTICIPATION:

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

LIMITED PARTICIPATION (ACTIVITIES ON BACK) COVER
DATES FROM ___________TO ___________

ALL YEAR ALTERNATIVE ACTIVITIES:
_____ Air Dyne Bicycle (upper, lower body or both)
_____ Treadmill
_____ Pace Walking
_____ Step Machine
_____ Weight Training (upper, lower body or both)
_____ Jogging

FIRST SEMESTER ACTIVITIES:
_____ Flag Football
_____ Archery
_____ Fitness Assessment (Physical Best Test)
_____ Golf
_____ Frisbee Games
_____ Fitness Assessment (Project Fit America)
_____ Indoor Soccer Games
_____ Basketball
_____ Gymnastics
_____ Weight Training and Conditioning

_____ Self Defense
_____ Volleyball

SECOND SEMESTER ACTIVITIES:
_____ Recreational Games (Team Handball, Floor Hockey)
_____ Cross Country Skiing
_____ Bench Aerobics
_____ Jump Rope for Heart
_____ Reebok Slide
_____ Thera-bands
_____ Tinikling
_____ Juggling
_____ Badminton
_____ Table Tennis
_____ Social Dance
_____ Track and Field Activities
_____ Physical Best Test
_____ Softball

PHYSICIAN'S SIGNATURE: _________________________________

DATE: _________________