St. Mary School-Riverside

The New Physical Education

A National Program of Health and Physical Education

Report of Injury, Illness and /or Operation

Dear Parents,

It is very important for your child's physical education teacher to be made aware of any injury, illness, or operation that your child has had that may affect his/her performance in class. (For example: allergies, asthma, diabetes,a broken bone that did not heal properly, etc.)

Please complete this form and return it to your child's classroom teacher by September 9th. Thank You.

My child does not have any physical problems or illness that will prevent his/her participation in physical education.

My child does have a problem that may hinder his/her participation. Please describe below.

Type of Injury, Illness, or Operation. Date. Prognosis.

Parent Signature

Once again, thank you for your cooperation

Principal

P.E. Teacher