Lake Region Union High School

Guidelines for ! Credit

Physical Education
The ! credit per the schools Wellness Policy requires students to complete 40 hours
of physical activity through individual monitored programs. A student will select the
manner in which this 1/4 credit is completed via a contract with an LRUHS physical
educator, family member, and a supervisor.
Program requirements:
Program must have prior approval from physical educator.
A final evaluation and reflection paper must be presented at course completion for
final approval by the physical educator.
A summer program must be approved prior to the close of school and final
submission of all documentation is due the first week the following school year.
A qualified supervisor/coach/instructor etc. of the student must be approved by
the same physical educator. This supervisor must complete the final
documentation.
The program must have a minimum of forty hours.
The student is responsible for the request and all documentation that is required.
All parties must sign the request form as well as the final documentation for the !
credit.
Lifetime 40 hour Request
Student Last Name:_________________________ First:_________________________
Course Title:_______________________________________________________
Primary Supervisor/Coach/Instructor:________________________________________
Physical Educator:_______________________________________________________
Dates of activity:_________________________________________________________
Grade/of Student:__________________ Projected Graduation Date:_____________
Student Name:___________________________________
Address:_________________________________ Phone:_____________________
Supervisor Name:_____________________________ Phone:_____________________
_______________________________
Student Signature
Date
_______________________________

Physical Educator

Date

__________________________________
Supervisor Signature
Date

Lake Region Union School

Final Evaluation for 40-hour Physical Education
Student Last Name__________________________ First__________________________
Course Title:_______________________________________________
Primary Supervisor/Coach/Instructor:________________________________________
Student Evaluation by Supervisor/Coach/Instructor:
(5 represents A, 4= B, 3= C, 2= D, 1= F)
Attitude-

5---4---3---2---1

Performance- 5---4---3---2---1
Responsible/Reliable: 5----4----3----2----1
Expectations met: 5----4----3----2-----1
Has completed forty hours: Yes-----No
Comments:______________________________________________________________
_______________________________________________________________________
Student Self Evaluation:
My Attitude: 5----4----3----2----1
My Performance: 5----4-----3----2----1
My Responsibility/Reliability: 5-----4----3-----2-----1
Meeting Expectations: 5----4-----3-----2----1
I have completed 40 hours: Yes-----No
My
Comments:______________________________________________________________
_________________________
Supervisor Signature Date
_________________________
Educator
Date

__________________________
Student
Date

Final Reflection
40-Hour Physical Education
Attach your typed reflection paper (no less than " page) to your final evaluation by you
and your supervisor. This is due when all course work is completed. Your reflection
paper is your reflection of this ! credit required prior to your graduation. Your typed
reflection paper should include comments on:
Your time management
Your skills as an independent learner
Contract fulfillment
Whether or not this was a valuable experience for you
Any new interests or abilities as a result of your completion
Your greatest accomplishment(s) or most satisfying aspect(s)
How appropriate and independent activity option was for you-why/not