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)