AWS - Physical Activity Modification Request Form 2020

Physical Activity Modification Request Form
Part 1: To Be Completed By The Parent
Student Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number*
Grade*
Physician's Name*

First NameLast Name
Phone Number*
I give my permission for Aurora Waldorf School to contact the physician regarding the contents of this form to plan my child's physical activities at school.
Signature
Date*

MonthDayYear
Date
Part 2: To Be Completed By The Physician
Medical diagnosis
Duration of Condition

Short TermLong TermPermanent
The Condition is

ProgressiveNonprogressive
Date student may return to unrestricted activity*

MonthDayYear
Date
Date student will be reexamined*

MonthDayYear
Date
Functional Capacity

Unrestricted (no restrictions on contact or intensity)Self-limited (student is able to determine appropriate activities)Mild-restriction (only avoid vigorous activities)Moderate restriction (limits sustained, strenuous activities)Severe restriction (limits are severe)
Part 3: To Be Completed By The Physician

Check all activities that you consider to be appropriate for the student to participate in. Remember that all activities will be modified for student's ability level.
Locomotor Skills

WalkHopRunSlideSkipJumpGallopLeapGrapevine
Fitness:
Cardiovascular

Aerobic DanceJump RopeAerobic WalkJog/Run
Flexibility

Arm/HandBack/ AbdominalHip/PelvisArm/ShoulderHead/NeckLeg/FootLeg/Knee
Muscular Strength and Endurance

Curl UpsFree Weights (light)PlyometricsPull/Chin UpsPush Ups
Dance Activities

AfricanHip HopBallroomSquare/Contra DanceOther
Individual Skills (non contact activities or individual practice skills)

HikingCreek WalkingClimbing TreesArcheryBasketball SkillsSwimmingBouncingBowlingCatchingThrowingJugglingField HockeyTable TennisPickleballVolleyballTennisFrisbeeSoccerSoftballLacrosseFlag/Touch FootballTrack and FieldRapid Overhead MovementsKicking Dynamic ObjectsKicking Stationary ObjectsStriking Dynamic ObjectsStriking Stationary ObjectsFlag/Touch Football
Team Activities (game situations where contact with other students is likely to occur)

BasketballField HockeyDodgeballKickballFlag/Touch FootballFrisbeeLacrosseSoccerSoftballTrack and FieldVolleyballWrestling
Tumbling and Gymnastics

Balance BeamInverted ActivitiesClimbing RopeParallel BarsUneven BarsVaulting BoxPommel HorseSpringboardPyramid BuildingStunts and TumblingTrampoline
Types of Games

Chasing/FleeingCooperativePropelling/ReceivingTagging
Provide additional comments that will aid in the modification of physical activity for this student:
Physician Signature*
Submitter's Email*
example@example.com
Should be Empty:

Physical Activity Modification Request Form

Part 1: To Be Completed By The Parent

Part 2: To Be Completed By The Physician

Part 3: To Be Completed By The Physician