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4316-E.4, Physical Education Exhibit

Application For Alternate Physical Education Instruction

Guidance Counselor: _______________________________
School: _______________________________

Name: _______________________________ Grade: ____ HR:____ Date: ______________

Instruction In: _________________________ Instructor and/or Organization: __________________________

Where Instruction will be performed: ____________________________________

When Instruction will be performed (dates): _______________________________

Days of week instruction is offered: ______________ Time of day Instruction is offered: ______________

Starting date of instruction: ______________ Completion date of instruction: ______________

Length of each lesson in minutes: _____ Number of times each week instruction is offered: _____

Total lessons offered: _____

Quarter offered (circle one) l 2 3 4

Signature of Off-Campus Instructor: _______________________________

Address: ______________________________________________________________
Business Phone ______________

If permission is granted for me to take this instruction, I agree to assume all responsibilities for
successfully completing the above instruction.

Student’s Signature: _______________________________

I hereby agree to assume any and all costs connected with the instruction listed above and _give my
permission for my child to take this out-of-school instruction in place of his/her regular Physical
Education class for the time specified. I realize that the North Colonie Central School District IS not
liable for any action of the sponsoring organization or its employees.

Parent or Guardian Signature: _______________________________

Program Coordinator Signature: _______________________________

Permission Granted to take outside instruction for comparable P.E. Credit ______________

Request Denied ______________

Signed by Director of Physical Education: _______________________________
Date: ______________

Copy to:
Hall Office
Guidance Office

Note: Prior exhibit, 5125.3 (f)