Sample Return to Physical Activity Form (Non-Concussion Medical Illnesses/Injuries)

Tools & Resources

Description

This sample form is intended to serve as a guide for stakeholders to create a form that aligns with the policies and procedures in their respective school division/school.

The Return to Physical Activity Form (Non-Concussion Medical Illnesses/Injuries) must be completed by parents/guardians and returned to the principal/designate for any student who has missed a physical education class due to an injury or illness requiring professional medical attention (for example, medical doctor, nurse practitioner, chiropractor, physiotherapist).

Name of Student:

Teacher:

Results of Medical Examination

As a result of my child’s/ward’s injury/illness, (insert injury/illness), medical attention by a (check one) [Medical doctor/Nurse practitioner/Other medical specialist] has been accessed with the following results (check appropriate box(es)):

No limiting features of the injury/illness have been observed and therefore he/she may resume full participation in physical activity with no restrictions.

Some features of the injury/illness remain which limit the ability to participate without restrictions. My child/ward may participate in physical activity following the accommodations to his/her physical activities listed below. (Accommodations must be provided prior to any physical activity taking place.)

A diagnosis that the injury/illness will prevent my son/daughter from participating in physical activity until further notice was received.

Refer to comments below and/or attached information.

Parent/Guardian signature:

Date:

Comments:

Recent Resources

Dec. 07, 2025

Index Scale and Weather Information

Dec. 07, 2025

Physical Activities of Higher Risk – Requirements for Day and Overnight Trips

Sep. 18, 2025

Concussion Protocols

Sep. 16, 2023

MPASS Revisions – September 2023

Jul. 07, 2023

Waivers and Informed Consent

Have questions? Ask MPASS

Please let us know what your questions are. You can submit inquiries regarding existing safety plans, feedback on website functionality, and suggestions / requests for new activity safety plans.

Ask MPASS