Fillable Monroe-Woodbury CSD Health Office (Monroe-Woodbury Central School District)

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Monroe-Woodbury CSD Health Office (Monroe-Woodbury Central School District)

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Monroe-Woodbury CSD Health Office
PHYSICAL EDUCATION MEDICAL
RECOMMENDATION FORM
Student Name: _______________________________ Date: _________________________
Diagnosis: ______________________________________________________________________________
All students are required by New York State Education Law to attend physical education classes. Any student
who is unable to participate fully in the entire program must have activities modified to meet his/her
individual needs. In order to modify _______________________________________ activities, please
complete the form below.
If activity is limited, please check what he/she SHOULD NOT do in the following list:
Activity Type Activity Type Activity Type Activity Type Activity Type
Bending
Hanging
Kicking
Pushing
Swimming
Body contact
Hitting
Lifting (lower body)
Running (distance)
Throwing
Catching
Hopping
Lifting (upper body)
Sprints
Tumbling
Climbing
Jogging
Lunging
Squatting
Twisting
Diving
Jumping
Pulling
Stretching
Walking
Above floor level activities (i.e. balancing)
Other (specify)
Check any activity this student SHOULD NOT participate in:
Activity type Activity type Activity type Activity type
Aerobics
Cross Country
Gymnastics
Swimming
Archery
Diving
Ice Hockey
Tennis
Baseball
Field Events
Lacrossse
Track
Basketball
Field Hockey
Skiing
Volleyball
Bowling
Football
Soccer
Weight Training
Cheerleading
Golf
Softball
Wrestling
Additional Physician’s Comments: _____________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
_____________________________ _____________________________
__________________
Physician’s Name (Please Print) Physician’s Signature Date
_____________________________
Physician’s Phone Number
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Monroe-Woodbury CSD Health Office (Monroe-Woodbury Central School District)

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Completed 23 December 2020

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