__________________________________  needs to be excused from 
work / school / physical education for the following dates: 
___________________________________________________________.  
He / she may return to work / school but still avoid physical 
activity as of:____________________________________________.  
He / she may return to full physical activity as of ________ 
___________________________________________________________.  
Additional comments / instructions:_________________________ 
____________________________________________________________ 
___________________________________________________________.  
____________________________________________________________ 
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