Loudoun County Public Schools
Restricted Activity Checklist
Student Name________________________________________ Grade________ School______________________________________________
This form should be completed by the physician indicating activities that the student CAN perform while recovering from illness or injury. If a student requires an alternative plan for physical education (i.e., a long term recovery or permanent condition, please notify the school to initiate adapted physical education services).
As required by the Standards of Accreditation established by the Virginia Board of Education, all students in elementary and middle school are required to participate in a program of physical activity (Standard 8 VAC 20-131-80; 8 VAC 20-131-90). High school students are required to complete 2 standards units of Health & Physical Education credit for graduation. This checklist is intended for students with a temporary condition that may restrict physical activity during physical education classes.
Date Student may return to unrestricted activity: ___/____/___
The student CAN participate in the following activities while recovering from injury or illness:
Low impact aerobic activities: walking, pedometer activities
Moderate impact aerobic activities: jogging, core training, dance
High impact aerobic activities: running, aerobics
Weight training: upper body
Weight training: lower body
Physical contact activities: group sports and games
Minimal physical contact activities: individual/dual sports (tennis, archery, badminton, disc golf, etc.)
Non-contact activities: core training, yoga, Pilates, dance, skills building (drills)
Stretching: yoga, Pilates, etc.
PT supervised during class per approval by PT and doctor
Please sign and FAX to school. School FAX number: _________________________________________