• 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:  _________________________________________



    Signed: ____________________________________________________


    Date: ______________________________________________________


    Address: ___________________________________________________ 


    Phone: _____________________________________________________