Physical Education And Sports Exemption
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1Physical Activity Exemption Request
Name
Age
Grade
Address
School
To the teacher/coach:
The student was examined on
and presented with the following conditions:
Participation in regular physical education classes and/or sports activities should be as follows:
No restrictions; Student may return to regular athletic activity as of:
Complete. Student should not participate in any athletic activity.
Partial; Please excuse the student from the following activities:
All, other than exercises prescribed.
Swimming
Endurance tests
Marching
Speed exercises
Strength tests
Dancing
Competitive physical games
Warm-ups
Others:
Duration of the exemption:
For school year
For the following period:
Until:
Until next examination
Other details & Notes:
Doctor’s Signature:
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Parent category: Legal