Excused from Physical Activities
This form is to be filled out by a parent or legal guardian when a child is to be excused from physical activities. This form will only be valid for up to three days. If a child's condition extends longer than three days, the child must see a medical doctor. Doctors notes must list the dates excused, return to activity date, and reason for excuse or specific limitations/modifications.
When a child is excused from physical activities during the school day this extends to physical education, recess, school sponsored athletics/intramural s, and other special events such as a field day.
This form is received by the Tenafly Middle School Nurse and the Vice Principal and shared with the appropriate faculty.
Student Last Name *
Student First Name (Legal name followed by nickname if applicable) *
Student ID Number *
Grade and Team *
Adult filling out this form Name and Relationship to Student *
Your Contact Phone number
Nature of student's Illness or Injury (limitations/modifications) *
If a child is ill they should not be in school. If a child not able to participate in physical activities,or is able to partially participate with limitations please specify IE: recovering from bronchitis, no vigorous activity/running
This parent/guardian note is valid for *
After three days, a medical doctors note is required.
Student's Physical Education teacher or coach *
This note automatically extends to physical education classes, recess, and after school athletic activities.
If applicable please also notify the following staff members/coaches of this note:
Nurse is automatically notified.
If applicable: Write the date of medical appointment for this issue, this way we may follow up with student and their teacher.
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