Physical Activity, Physician's Recommendations

Health Service Procedure Physical Activity Recommendation for Student with Orthopedic Appliance/Equipment CAST, CRUTCHES, WHEELCHAIR, OR SLING Students returning to school with a cast, crutches, a wheelchair, or a sling shall have a physician complete this... More

Health Service Procedure Physical Activity Recommendation for Student with Orthopedic Appliance/Equipment CAST, CRUTCHES, WHEELCHAIR, OR SLING Students returning to school with a cast, crutches, a wheelchair, or a sling shall have a physician complete this form and return the form to the Health Office. Student Name: ________________________________________ D. O. B: ____________________ Grade: ______________________ DATE OF INJURY: __________________________ TYPE OF INJURY/DIAGNOSIS: ___________________________________________ DURATION OF RECOMMENDATION BELOW: _______________________________________________________________________ Permission to be in school with: (Please check) □ Cast □ Crutches □ Wheelchair □ Sling □ Other ______________________________ Recommendations for Recess/Lunch: (Please check) □ May not participate in any physical activity □ May not participate, but may interact with peers in designated “safe areas” per school policy □ Other: __________________________________ Less