AWS - Physical Activity Modification Request Form 2020

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

First Name Last Name
Date of Birth *

Month Day Year
Date
Address *

Street Address

Street Address Line 2

City State / Province

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

First Name Last 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 *

Month Day Year
Date
Part 2: To Be Completed By The Physician
Medical diagnosis
Duration of Condition

Short Term Long Term Permanent
The Condition is

Progressive Nonprogressive
Date student may return to unrestricted activity *

Month Day Year
Date
Date student will be reexamined *

Month Day Year
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

Walk Hop Run Slide Skip Jump Gallop Leap Grapevine
Fitness:
Cardiovascular

Aerobic Dance Jump Rope Aerobic Walk Jog/Run
Flexibility

Arm/Hand Back/ Abdominal Hip/Pelvis Arm/Shoulder Head/Neck Leg/Foot Leg/Knee
Muscular Strength and Endurance

Curl Ups Free Weights (light) Plyometrics Pull/Chin Ups Push Ups
Dance Activities

African Hip Hop Ballroom Square/Contra Dance
Individual Skills (non contact activities or individual practice skills)

Hiking Creek Walking Climbing Trees Archery Basketball Skills Swimming Bouncing Bowling Catching Throwing Juggling Field Hockey Table Tennis Pickleball Volleyball Tennis Frisbee Soccer Softball Lacrosse Flag/Touch Football Track and Field Rapid Overhead Movements Kicking Dynamic Objects Kicking Stationary Objects Striking Dynamic Objects Striking Stationary Objects Flag/Touch Football
Team Activities (game situations where contact with other students is likely to occur)

Basketball Field Hockey Dodgeball Kickball Flag/Touch Football Frisbee Lacrosse Soccer Softball Track and Field Volleyball Wrestling
Tumbling and Gymnastics

Balance Beam Inverted Activities Climbing Rope Parallel Bars Uneven Bars Vaulting Box Pommel Horse Springboard Pyramid Building Stunts and Tumbling Trampoline
Types of Games

Chasing/Fleeing Cooperative Propelling/Receiving Tagging
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