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_____________________________ ________________________________ _________ ___________
PASADENA CITY COLLEGE
STUDENT HEALTH SERVICES
1570 East Colorado Blvd., D105
Pasadena, California 91106-2003
626-585-7244 FAX 626-585-7933
Date:_____________
To: Medical Provider From: Coordinator
Re: ____________________________________________________ Lancer ID#: ______________________
The above named student is requesting an exemption from physical education. Pasadena City College requires
all students to complete two (2) units of physical education (PE) in order to complete general education
requirements toward an associate’s degree. Each PE class is one (1) unit. The class usually meets two-three
times/week for 1-1.5 hours. A maximum of three hours per week.
It is understandable that some students may have a medical condition that would prohibit them from participating
in regular PE classes. To accommodate students requiring a less rigorous program, Pasadena City College offers
other PE classes for students with physical restrictions.
Stretching Fitness (KINA 033) — Emphasis on achieving and improving level of flexibility through basic
stretching exercises.
Beginning Fitness (KINA 032A) — Emphasis on achieving an improved level of physical performance through
basic training with weights, circuits, aerobics and stretching programs.
Adapted Fitness (KINA 027A-B-C) — Emphasis on exercises to increase level of physical, motor, and postural
fitness through training with weights, stretching exercises and relaxation techniques. This class is designed for
physically disabled or acquired brain injury individuals.
Beginning Aquatic Fitness (KINA 028A) — Physical fitness activities in the pool. (No swimming skill necessary.)
Regular Physical Education — Includes all levels of: swimming and diving; modern, jazz, and ballet dance;
fitness activities, body building, cycling, self-defense, badminton, fencing, golf, racquetball, downhill ski techniques,
basketball, soccer, volleyball, and intercollegiate sports.
Student Health Services is committed to helping students maintain their wellness and meeting the college
curriculum requirements. If, in your clinical judgment, your patient could benefit from a modified PE class,
please indicate below which activities are most appropriate. Please add specific information that may be
helpful to your patient in working with the Kinesiology, Health and Athletics Division.
Date:_______________ Medical Diagnosis: _______________________________________________
Physical Restriction: ____ Temporary ____ Permanent Beginning ___________ Ending:__________
Date Date
May participate in: ____ Stretching Fitness (KINA 033)
____ Beginning Fitness (KINA 032A)
____ Adapted Fitness (KINA 027A, B, C)
____ Beginning Aquatic Fitness (KINA 028A)
____ Regular Physical Education Class
Comments: ______________________________________________________________________________
Medical Provider: Phone:__________________ FAX:_____________________
(Print) Name Signature Degree State Lic. No.
SHS220 1/12 Rev. 8/18
