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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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