Placentia­Yorba   Linda   Unified   School   District Physical   Education   Exemptions 

  Last   Name: ____________________________________  First   Name:    ____________________________   M.I.    _________   Birth   Date:    ___      ___      /      ___      ___      /      ___      ___      ___      ___   Student   ID:    ________________   Grad   Year:   20    ___   ___  Physical   Education   Exemptions:  For   Middle   and   High   School Please   complete   attached    Physical   Education   Medical   Exemption   Approval   Form  

❏ Temporary :   “The   governing   board   of   a   school   district   or   the   office   of   the   county   superintendent   of   schools   of   a   county may   grant   temporary   exemption   to   a   pupil   from   courses   in   physical   education,   if   the   pupil   is   one   of   the   following: 

❏ (1)   Ill   or   injured   and   a   modified   program   to   meet   the   needs   of   the   pupil   cannot   be   provided. ❏ (2)   Enrolled   for   one­half,   or   less,   of   the   work   normally   required   of   full­time   pupils.”  

(EC   Section   51241   [a][1][2])  

For   High   School   Only  ❏ Two­year:    “The   governing   board   of   a   school   district   or   the   office   of   the   county   superintendent   of   schools   of   a 

county,   with   the   consent   of   a   pupil,   may   grant   a   pupil   an   exemption   from   courses   in   physical   education   for   two years   any   time   during   grades   ten   to   twelve,   inclusive,   if   the   pupil   has   met   satisfactorily   any    five   of   the   six standards    of   the   physical   performance   test   administered   in   grade   nine   pursuant   to   Section   60800.” (EC   Section   51241   [b][1 ]) 

 9 th       Grade   CA   Physical   Fitness   Test   Score :   _____________________________________  

 ❏ Permanent :      “The   governing   board   of   a   school   district   or   designee   may   grant   permanent   exemption   from   courses   in 

physical   education   if   the   pupil   complies   with   any   one   of   the   following: ❏ Is   sixteen   years   of   age   or   older   and   has   been   enrolled   in   the   10th   grade   for   one   academic   year   or   longer. ❏ Is   enrolled   as   a   postgraduate   pupil. ❏ Is   enrolled   in   a   juvenile   home,   ranch,   camp,   or   forestry   camp   school   where   pupils   are   scheduled   for 

recreation   and   exercise   pursuant   to   the   requirements   of   Section   4346   of   Title   15   of   the   California   Code   of Regulations.”   (EC   Section   51241   [c][1][2][3]). 

 Student’s   explanation   for   exemption   request:   ________________________________________________________________________________________________________  ________________________________________________________________________________________________________   Student   Signature:    ____________________________________________________   Date:    _______________________  

❏ Approved:    Above   student   meets   qualificaĕons   for   exempĕon.      Evidence   of   qualificaĕon   is   aĥached.  

❏ Denied:    Reason   ________________________________________________________________________________  

Administrator’s   Signature:    ______________________________________________       Date:    _______________________  

Administrator   Name:    ________________________________________________________________________________  

 

Placentia-Yorba Linda Unified School District PHYSICAL EDUCATION MEDICAL EXEMPTION APPROVAL FORM

School name:_________________________________________________________________ School address: ______________________________________________________________ _______________________________________________________ _________________ Signature, Principal Date Part I: TO BE COMPLETED BY THE PARENT/GUARDIAN Student name: _____________________________________ Date: _____________________ Address:__________________________________________ Home phone: ______________ School:___________________________________________ Date of birth: _______________ Physician’s name: __________________________________ Phone: ___________________ I give my permission to the Placentia-Yorba Linda Unified School District to contact the health care provider and confidentially and discreetly use the content of this form to plan my child’s Physical Education Program. _______________________________________________________ __________________

Signature, Parent/Guardian Date Part II: TO BE COMPLETED BY THE HEALTH CARE PROVIDER Medical diagnosis: _____________________________________________________________

Duration of the condition: ! Short term ! Long term ! Permanent The condition is: ! Progressive ! Non-progressive

Date student may return to unrestricted activity: ______________________________________ Date student will be reexamined:__________________________________________________ Functional capacity (Please check one and complete form on the other side) ! Unrestricted (No restriction on contact or intensity) ! Self-limited (Student is able to determine appropriate activities) ! Mild restriction (Only avoid vigorous activities) ! Moderate restriction (Limits sustained, strenuous activities) ! Severe restriction (Limits are severe)

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Part III: TO BE COMPLETED BY THE HEALTH CARE PROVIDER. Check all activities that you consider to be not appropriate for the student to participate in. Remember all activities will be modified for student’s ability level. Locomotor Skills: ! Walk ! Hop ! Run ! Jog ! Skip ! Jump ! Leap Fitness: Cardiovascular ! Aerobic Dance ! Exercise Bike ! Jump Rope ! Step Aerobics ! Treadmill ! Jog/Run ! Rowing Machine ! Stair Stepper Flexibility ! Arm/Hand ! Back/Abdominal ! Hip/Pelvis ! Leg/Knee ! Arm/Shoulder ! Head/Neck ! Leg/Foot Muscular Strength and Endurance ! Curl-ups ! Free Weights (light) ! Plyometrics ! Pull-ups

! Weight Machines ! Push-ups Individual/Dual Skills and Activities (non-contact activities, individual and partner practice skills): ! Badminton ! Basketball ! Bouncing ! Bowling ! Flag/Touch Football ! Floor Hockey ! Frisbee ! Golf ! Gymnastics/Tumbling ! Handball ! Lacrosse ! Pickleball ! Racquetball ! Soccer ! Softball ! Swimming ! Tennis ! Track and Field ! Volleyball ! Catching ! Throwing ! Kicking Dynamic Objects ! Striking Dynamic Objects ! Rapid Overhead Movements Team Activities (Game situations where contact with other students is likely to occur): ! Basketball ! Field Hockey ! Flag/Touch Football ! Floor/Street Hockey ! Frisbee ! Lacrosse ! Soccer ! Softball ! Team Handball ! Track and Field ! Volleyball ! Other________________ Types of Games: ! Chasing/Fleeing ! Cooperative ! Propelling/Receiving ! Tagging Provide additional comments that will aid in the modification of physical education for this student: _____________________________________________ __________________________ Signature, Health Care Provider Date Return form to your child’s school office. www.pylusd.org September 2015