Excuse from Work, School, or Physical Activity

__________________________________________________ needs to be excused from:

_____ Work

_____ School

_____ Physical activity

Beginning now and through the following date: ____________________

_____ He/she may return to work or school but still avoid physical activity from now until: ____________________

_____ He/she may return to full physical activity as of: ____________________

Caregiver's signature: ________________________________________

Date: ______________________________________________________