Student Name_____________________________________ Year of Graduation:__________
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Approved Outside Physical Activity Experience:

Approved Physical Activity:_________________ Guidance Counselor Name:__________________

Students who are seeking approval to use an outside physical activity to fulfill the physical education requirement for the year, must first complete an appeal form and send in by the due date. In order for a student to receive credit for an approved outside activity, the following criteria must be completed:
· Keep a daily log of the hours of participation, nature of activity and receive a daily signature from the trainer or instructor. This signature signifies that the instructor is verifying participation for the number of hours designated.
· Meet periodically with the Athletic Director. This should be logged and signed by the Athletic Director. The signature represents that you did meet to discuss your progress on your outside activity.
· Provide a written assessment explaining how this activity incorporated the five health related components of fitness. This must be submitted to the Athletic Director for a grade.

School Sport:

Sport:_____________________ Season _________ Guidance Counselor Name:______________________

Students electing to participate in a school sport to fulfill the physical education requirement, must meet the following criteria to receive credit:

· Attend all practices and participate completely
· Attend all games / meets
· Receive a signed certificate from the athletic director indicating successful completion of the season

Coaches will maintain attendance records for both practices and games.

All criteria must be 100% met in order to receive course credit. An outside physical education experience or school sport that was not successfully completed will need to be made up in a scheduled physical education course either the following semester or the following year or the course can be made up in a summer school program if one is available (the school is not obligated to provide a summer school course). If a student does not make the cut of a spring sport, they will either have to make up the missed physical education experience in a summer school program or in a scheduled class the following year. A student is not eligible to use a school sport or outside physical education learning experience to make up a failed physical education experience. If a student is a senior and they do not make the cut for a spring sport or they do not successfully complete the season, they will not graduate unless they successfully complete a summer school physical education program. Failure to make up a physical education experience will result in a failed grade and may result in the failure to graduate high school. It is not the responsibility of the school to provide a summer school physical education program. It is important for seniors to understand that successfully meeting the criteria is essential to graduate.

I __________________________________ have read and understand the above requirements. I understand
Student Signature
that if I do not successfully meet the criteria, I will receive a failing grade which may impact graduation.
_______________________________________ ______________
Parent / Guardian Signature Date

Wellness Department: Physical Education

Alternative Physical Activity Documentation
(To be completed only by those students who are using an approved outside physical activity to fulfill the physical education requirement)

Student Name: _________________________________
Grade Level :___________
Name of Physical Activity: _______________________________
Name of Certified Coach or Trainer:____________________________
Contact Number of Coach/Trainer:_______________________

This form will be used to provide documentation of your participation in the activity stated above. Your coach/trainer is responsible to complete this tracking sheet at the end of each session you complete. You must meet with the Athletic Director (Mr. Brian Carroll) a minimum of 6 times in a semester to discuss your progress in the activity.

Date of Session Hour(s) of Participation Day’sPrimaryObjectives Coach/Trainer Signature Total Hours Accrued Meetings with Athletic Director

Date of Session Hour(s) of Participation Day’sPrimaryObjectives Coach/Trainer Signature Total Hours Accrued

2010-2011 Physical Education Appeal Form
This form must be completed by those students seeking to use an outside school physical activity to fulfill their physical education requirement

To meet Massachusetts Department of Education requirement all current 10th and 11th graders need to fulfill a physical education requirement during both their junior and senior year. At this time, the requirement can be fulfilled in one of two ways:
· Successful completion of one Physical Education course each year
· Full participation and completion of one Winchester High School after school sport. (the student must receive a signed certificate from Athletic Director, Mr. Brian Carroll)

In rare situations, students who are involved in a rigorous physical activity program outside of school may be able to apply this experience towards fulfilling the physical education requirement. In order for the program to be considered it must meet the following criteria:
· Take place under the instruction of a certified coach (copy of current certification should be submitted)
· Engage the student in a minimum of 90 hours of rigorous activity per semester
· Include the following health related components of fitness: body composition, muscular endurance, muscular strength, flexibility and cardiovascular endurance.

Physical Activity in a workout club or gym will not be accepted.

If you believe you have such a situation, please complete the form below in its entirety and submit to Jeannine Lavoie, Director of Wellness by March 26th. The appeal will be reviewed and you will be notified of the decision. If the appeal is approved you will need to complete the Alternative Physical Education Contract and submit it to the Athletic Director, Mr. Brian Carroll Please note that if the appeal is approved, upon completion of the semester and to receive course credit, the student will be required to 1. Provide a written assessment explaining how this activity incorporated the five health-related components of fitness and 2. Submit the record of attendance, completed and signed off by the coach 3. Meet periodically throughout the year with the athletic director to assess progress.

Student name: _____________________________________ Year of Graduation: __________
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Parent/Guardian Name:__________________________ Guidance Counselor Name_________________

Guardian Contact number and email address:________________________________________________

Name and Description of Program Include number of days per week and hours per day of participation ___________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________
Name and contact number of Coach:________________________________________________________

Approved Not Approved _____________________________________
Wellness Director’s Signature