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 RESUMEEmployer*Phone (including area code)*Employment Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Do you possess an active certificate for CPR?*Select OneYesNoDo you possess an active certificate for First Aid?*Select OneYesNoWhat certificate or training qualifies you to coach this activity?*Have you ever been convicted of anything other than a minor traffic violation?*Select OneYesNoPlease Explain:*INSTRUCTOR INFORMATIONAcknowledgement*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
