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					Dear Physician,

The School Laws of Pennsylvania require all students to take Physical Education while attending school.
If a student is unable to take regular Physical Education, schoools are required to modify or adapt a
program for the typical student.

Before a student can be placed into an adaptive or modified program, Tamaqua Area High School requires
that the student's physician complete the adaptive P.E. form. This information will assist the instructor
in designing a program.

Name:                                                          Grade:

Nature of Injury:




Dates Applicable:              From                                     To

The following options are offered within the normal Physical Education classes. Please check any in
which the student is ALLOWED to participate.

                           9th-10th Grade Physical Education
Ist Quarter                Second Quarter        Third Quarter                Fourth Quarter
Physical Fitness           Swimming              Swimming                     Wt. Training
                           Line Dancing          Line Dancing                 Softball
                           Advent.Act.           Advent. Act.                 Tennis
                                                                              Volleyball

                                       11th - 12th Grade Physical Education
    Ist Quarter             Second Quarter          Third Quarter        Fourth Quarter
Archery                    Bowling                  Badminton             Softball
Racquetball                Table Tennis             Wt. Training          Volleyball
Tennis                     Adv. Line Dan./          Water Polo            Golf
Rec. Sports                Adv. Activities                                Fitness
(Horseshoes, Croquet or                                                      Walking
Ultimate Frisbee)
Are there any restrictions within the options checked above?


If none of the above are possible, could you prescribe an exercise program, walking, or some other option?


          Date                                       Physician's Signature:

Print (or type) name of physician:

                           Address: