Hurricane Intermediate Physical Education
Activity Limitation/Restriction Form
Students Name____________________________________________Date_______________
Onset of Illness/Injury (Date):___________________________________________________
Description of Injury/Illness:____________________________________________________
____________________________________________________________________________________
*Student is temporarily restricted from participating in the following types of
activities (please check all that apply and set duration of restriction/limitation):
*When a student has a physically limiting or restricting condition, they are still expected to dress for P.E.
and participate within the parameters of their designated limitations/restrictions. Missed assignments will
be postponed until restriction/limitation is removed. If the condition prohibits all activity or is expected to
continue for more than three consecutive school days, a physician’s note may be requested.
Parent Signature:______________________________________________________________________________
Click on link below to access pdf version. Then follow step A or B.
A: Print and send completed form to school with student.
B: Copy and paste form into an email belonging to a parent, complete form, and send email to P.E. teacher.