Graduation Transitions 12 DPA Verification Form

Each area must be completed according to the stated criteria in order for the requirement to be met.

Personal Health Component

Physical Activity Verification Form for Sports or Community Club

Student Name: Organization/ Club/ Team: ___________________________________________________
(First Name and Last Name

__________

Address:________________________________________________________________________________ Coach/Sponsor/Instructor:
(First Name and Last Name

__________ __________

Coach/Sponsor/Instructors Contact Phone Number:

Coach/Sponsor/Instructor
I would like to confirm that (name) has completed a total of (date) hours of moderate to vigorous physical activity as part of the DPA requirement of the Graduation Transition Plan. The activity was completed between to (date). He/She has engaged in minimum 2.5 hours of physical activity per week.

The type of physical activity:

Overall Performance & Attitude: Excellent Good

Performance and participation comments (optional):

Fair

Poor

__________________________________ Signature: __________________________________ Date: