Safety Guidelines for Secondary Interschool Athletics in Alberta

APPENDIX D - Sample Request to Resume Athletic Participation
One of these forms is to be completed and returned to the teacher/coach by any student athlete who has
missed a practice or game due to an injury or illness requiring professional medical attention.
MEDICAL PROFESSIONAL FORM
This form is to be completed by a medical professional, e.g., physician, chiropractor, physiotherapist.
I, _________________, (name of professional) have tested/examined ___________________, (name of
student athlete) after an injury/illness to or affecting his/her___________________________________,
(body part) and certify that, in my professional opinion, he/she will be ready to resume participation in
__________________ (name of interschool athletic activity) as of ________________________ (date).
COMMENTS:________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
Signature:_______________________________________ Date:_____________________________
PARENT/GUARDIAN FORM
This form is to be completed by a parent/guardian.
I, ______________________________________________________________, (name of
parent/guardian) acknowledge the fact that ______________________, (name of athlete) has received
care for an injury/illness affecting his/her __________________, (body part) and request his/her
participation in _________________________ (name of interschool athletic activity) resume on
_______________________ (date).
COMMENTS:_____________________________________________________________________
Signature:_______________________________________ Date:_____________________________
Safety Guidelines for Secondary Interschool Athletics in Alberta - February 2012 75