School Excuse

Child's name __________________________________________________





Diagnosis _____________________________________________________





This child was home for medical problems from _______________ to



_____________________.



This child is now able to return to school and is not contagious.





Physical education:



___ Full activity



___ Limited activity as follows:



_______________________________________________________________



_______________________________________________________________



_______________________________________________________________



No gym for _____ days





Physician's name ______________________________________________



Physician's signature ________________________ Date ___________



Physician's phone number _________________________

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