Independent Study Physical Education: Instructor’s Statement of Responsibility

The supervision of Independent Study activities must be performed by a coach who is at least 21 years of age, who has a certificate or a credential in that activity, or who has participated at least 4 years at a college/national or international level in that activity. I understand the concept and requirements of the Independent Study (Physical Education) Program and accept the responsibility as coach.

Site Administrator's Name*
First Last
Email*
Phone (including area code)*
COACH'S RESUME
Employer*
Phone (including area code)*
Employment Address*
Street Address City State ZIP Code
Do you possess an active certificate for CPR?*
Do you possess an active certificate for First Aid?*
What certificate or training qualifies you to coach this activity?*
Have you ever been convicted of anything other than a minor traffic violation?*
Please Explain:*
INSTRUCTOR INFORMATION
Acknowledgement*
- I will PERSONALLY oversee this athlete's workouts for a minimum of 150 minutes a week. In addition, I will sign his/her time logs, as well as PERSONALLY write his/her progress report and trimester evaluations which will include a one page statement evaluating the athlete's participation and progress towards stated goals and objectives. If there are any questions regarding the Independent Study Program, or the athlete, please contact the Site Administrator at the athlete's school site.
Instructor's Name*
First Last
Email*
Phone (including area code)*
Instructor's Signature*
Athlete's Name*
First Last

Independent Study Physical Education: Instructor’s Statement of Responsibility

COACH'S RESUME

INSTRUCTOR INFORMATION