Northview Public Schools

Physical Education Health Status Form

Dear Parents/Guardian,
In an effort to have important health information about each student immediately available, we
ask all parents/guardians to please complete this form and return it A.S.A.P. with your student to
their physical education teacher.
Childs Name______________________________________________________
Grade_______________
Classroom/Homeroom/Seminar Teacher_________________________________
Are there any medical conditions that limit your childs participation in vigorous
physical activity? Yes______ No______
If yes, please describe/explain__________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
Is your child currently taking any medication?

Yes______

No______

If yes, please describe/explain__________________________________________

__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

Note: If this information changes please send a note with your child indicating the change.
Also, if your child gets injured during the school year or becomes ill, please send a doctors note
if he/she will miss two days or more of physical education.
Thank you.
Parent Signature_________________________________
Parent Phone Number_____________________________