• Physicians Activity Checklist

     

    Loudoun County Public Schools

    Allowable Activities 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 particular 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.

     

    Stationary bicycle

     

    Other:

     

     

    Please sign below and submit to the patient’s Health and Physical Education teacher at the school of attendance in LCPS.



    Signed: ____________________________________________________

     

    Date: ______________________________________________________

     

    Address: ___________________________________________________  

       

    Phone: _____________________________________________________