Dear Physician, OSF St. Mary Medical Center Rehabilitative Services Department is beginning a Splashtastics aquatics course. This class is an hour of fun filled aquatic games, exercises, and play for children with disabilities 5 –10 years of age. The classes are designed as exercise courses, not as therapy. The purpose of this class is to provide children with disabilities the chance to participate in age appropriate structured play in a supportive and carefree environment. Activities and games are designed to encourage appropriate socialization, attention to task, fitness, and sensory opportunities. We believe that in the best interests of the individuals it is important for all participants to communicate with their physician and receive clearance for their participation in this program. Thus, in order to ensure the safety and well being of each participant we are asking that class members receive their doctor's consent to participate. By signing this consent form you are releasing __________________________________ to participate in the Splashtastics course. Thank you for allowing your patient to participate. If you have any questions or concerns please feel free to contact Cortney Kicielinski, PT at 309-344-9600. Sincerely, I hereby release ___________________________ to participate in the aquatic course offered by OSF St. Mary Medical Center Rehabilitation Services Staff. I understand the class is not therapy, but an exercise class designed specifically for children with disabilities.
______________________________
______________________________ |