SMUSD Medical Form

Physical Education Modifications for Injury or Illness

To parent and/or healthcare provider of (student)________________________________________

Date of Birth:_______________

The school district recently received a request to exempt the above-named student from physical education for reasons of injury or illness. Under California Education Code, Section 51241, exemption from physical education may be granted temporarily for an ill or injured student only if “a modified program to meet the needs of the pupil cannot be provided.”

To comply with California state law, this district cannot completely exempt a student from physical education until it is established that PE modifications cannot be safely provided. To do so, district health and PE personnel must understand the nature of a student’s illness or injury, as explained by the student’s licensed health care provider.

Please note that:

  • A physician's note is necessary, but may be insufficient, to completely excuse a student from PE if the note does not adequately explain how a modified PE program is inappropriate or unsafe.
  • Adaptive or modified PE programs may safely accommodate a student who is well enough to otherwise attend school.

This form may be used by the managing licensed health care provider to describe the medical/orthopedic condition or injury. Return form to school staff at the fax number listed below:

Date of injury or onset of illness: ______/______/______

Diagnosis or condition limiting activity: ______________________________________________________________________________


Anticipated duration of limitation (or date full PE participation is permitted): ______________________________

Specific limitations to activity: (checked selections denote student may participate in the activity, modified at the discretion of school staff). THE STUDENT CAN participate in the following:

Tier 1

❏ Aerobic exercise

❏ Vigorous lower extremity exercise (e.g. running, jumping, kicking, jogging)

❏ All strength exercise (indicate if limited to upper body, lower body, etc):______________________________

Tier 2

❏ Light lower extremity exercise (e.g. walking, stationary bike)

❏ Upper extremity exercise/weight bearing (e.g. lifting, throwing)

Tier 3

❏ Stretching and flexibility exercises (indicate if upper body, lower body, etc):______________________________

❏ Written assignments

❏ Other (specific limitation, please describe):__________________________________________________


Health Professional (printed name) Signature CA License # Telephone #

Student’s healthcare provider may reach the following school staff member to explore PE modifications or to discuss limitations of the student:_____________________________________


School Staff Member to Contact Telephone # Best Days/Hours to Reach Fax #

SMUSD Medical Form

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