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Newport News Public Schools
Physical Education Department
Physician’s Modified Activity Form
Student Name: ____________________________________________ Grade: _____ School: __________
Dear Healthcare Provider,
According to Virginia state law, two semesters of physical education are required for high school graduation. Newport
News Public Schools encourages students to continue to participate in physical education as medically appropriate.
Please identify the student's functional abilities, recommended participation level, and any necessary restrictions or
precautions so the physical education teacher can provide safe and meaningful activities.
Student CAN Participate In (Check all that apply)
☐ Regular PE activities with no restrictions
☐ Walking
☐ Jogging/Running
☐ Jumping/Hopping
☐ Balance & coordination activities
☐ Stretching/Flexibility activities
☐ Strengthening activities
☐ Throwing/Catching skills
☐ Modified sport activities
☐ Non-contact activities
☐ Contact activities
☐ Seated/Adapted activities
☐ Other: ____________________________________________
Activities to Avoid or Modify (if applicable)
☐ Running/Sprinting
☐ Jumping/High impact activities
☐ Contact activities
☐ Heavy lifting
☐ Weight-bearing activities
☐ Repetitive movements
☐ Overhead movements
☐ Specific movements/activities:
_________________________________
Medical Restrictions, Precautions, or Recommendations
(Include limitations, monitoring needs, equipment needs, or other considerations.)
Physician Name (Print): _________________________________Phone: __________________________
Physician Signature : __________________________________________________ Date: _____________
Thank you for partnering with Newport News Public
Schools to support safe and meaningful participation
in physical education. For questions regarding PE
modifications, contact the Newport News Public
Schools Individualized Physical Education Department:
757-591-4971 ext. 28114.
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