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

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:
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:
Question Mark


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