Name: _______________ Date of injury: _______
Injury diagnosis: ____________________
Treatment: no activity (days) ____________ Physical therapy: Y/N
Surgery: Y/N (Date: _______)
Current status: rehab program: Y/N
Weekly dance warm-up: Y/N Weekly dance class: Y/N
Special Considerations
(e.g., dancer can do technique class but is not ready to jump)
____________________
____________________
____________________
____________________
____________________
____________________
____________________ ________
Signature of physician/physical therapist Date
____________________
Signature of dancer
NOTE: It is the dancer’s responsibility to: (1) have their health-care provider update this form as soon as their condition allows them to resume class, rehearsals, or performances, and (2) ensure that artistic staff has a current record of their injury status.