_________________ Public Schools INFORMED CONSENT TO PARTICIPATE IN PHYSICAL EDUCATION ACTIVITIES

Please complete this form on our website or return the form by: September 14, 2013

Student name:_________________________________________

Grade: _________

The following activities will be part of our physical education class this year. Please check yes if your child is able to participate or no for an activity if your child should NOT participate for medical or health reasons. Check limit and describe any limitations for his/her participation if he/she may participate with adaptations. If your student cannot participate at all during a unit of study, he/she will be given an alternate learning activity. The teacher will call you to discuss any limitations or alternative learning activities needed for your student.

P.ED. LEARNING ACTIVITIES Fitness activities Rollerblading/skating Outdoor pursuits/ hiking/ snowshoeing Jump roping Racket sports skills Team Sport skills: Basketball Soccer Flag Football Base/softball Volleyball Tennis/badminton Swimming Dance Gymnastics Rock Climbing Wall Weight Lifting

YES

NO

LIMIT EXPLANATION OF NO OR LIMIT

The student named above has my/our permission to participate in all class learning activities marked yes and in activities marked limit if adaptations are provided as described. Parent/Guardian printed name:_________________________________________________ Parent/Guardian signature:____________________________________________________ Phone number: ______________________________________________________________ Emergency contact name and number: ___________________________________________