· For the complete list of PE waiver requirements, please refer to the "Waiver of Physical Education Credit" page, attached to the application packet.
· Special circumstances may be considered. See PE Waiver Coordinator for questions. (ex. health conditions)
1. Waiver of Physical Education Credit
  1. 1. The waiver plan must be pre-approved by the Physical Education Waiver instructor within the first two weeks of the start of the activity or athletic program.
Washington State Physical Education
EVERETT SCHOOL DISTRICT
PE Waiver 2: Cognitive Assessment

EVERETT SCHOOL DISTRICT

PHYSICAL EDUCATION

WAIVER 2

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(Application for students completing their second PE waiver.)

EVERETT SCHOOL DISTRICT

PE WAIVER PROCESS


·	Student must have successfully completed PE 1 before being eligible for a PE waiver.
·	PE waiver applications must be pre-approved by the PE Waiver Coordinator
·	Complete PE Waiver Application form in ink.
·	Application forms are due as follows:
·	Fall: Second Friday in September
·	Winter: First Friday in December
·	Spring: Second Friday in March
·	Student has 2 weeks from the completion of the season/activity to complete and submit the waiver forms. Season end dates are as follows:
·	Fall: Second Friday in November
·	Winter: Second Friday in February
·	Spring: Second Friday in May
·	For the complete list of PE waiver requirements, please refer to the "Waiver of Physical Education Credit" page, attached to the application packet.

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·	Special circumstances may be considered. See PE Waiver Coordinator for questions. (ex. health conditions)


Granted Pre-Approval Start Date:_____________________


Due Date:_________________________________


Students are expected to meet the required due dates.

Waiver of Physical Education Credit
To be eligible for graduation, state law and Everett School District policy requires all students to complete a minimum of 1.5 credits of Physical Education. District policy allows high school principals to waive up to 1.0 credit of the Physical Education requirement. If a Physical Education credit is waived, the student is still required to complete a minimum of 22 or 24 total credits to graduate from high school (varies with student’s graduation year).

Purpose: The purpose of this waiver program is to provide students whose 4-year high school plan is filled with academic courses an opportunity to satisfy Physical Education graduation requirements. Students requesting a Physical Education Credit Waiver may not enroll in Teacher Assistant (TA), Early Release or Late Arrival during their four years. If open periods become available the four years, they will be filled with a physical education class. (Students with special health circumstances may be eligible for the waiver process which requires building Principal permission.) Upon completion of this packet students will have met newly adopted Washington State Physical Education Standards 1-5 outlined by OSPI and are eligible to waive a .5 credit of P.E. (RCW 28A.230.050)

Procedure: To be granted a waiver of Physical Education credit, students must meet the following criteria:

1. The waiver plan must be pre-approved by the Physical Education Waiver instructor within the first two weeks of the start of the activity or athletic program.

2. Student must have passed one semester of Introductory P.E.

3. Participate in directed athletics including community and school programs or participate in marching band or NJROTC.
4. Activities with personal trainers or individual workouts DO NOT meet the definition of "Directed Athletics" as required by state law and cannot be used for this waiver program.

5. Commitment from an adult coach (not a parent or guardian or other family member) to monitor your activity and verify such activity to meet the requirements.
6. Non-School sponsored sports must provide practice/competition schedules.
7. Documentation of 75 hours (0.5 credits) within two weeks of completion of designated sport/activity. Allowable hours include practice and competition/performance time only.

8. The student must finish the athletic program in good standing to receive the waiver. Each coach determines good standing for the program.

9. Completion of the required cognitive assignments within the packet.

EVERETT SCHOOL DISTRICT
Application for Alternative Program to Meet Physical Education Requirement
Directed athletics and activities must comply with parameters established by the Everett Public Schools' Risk Management Pool. Certain hazardous activities are prohibited. The district has the right to reject any activity that is judged to be unsafe.

Student Information

Name Student #

School Grade 9 10 11 12

Address

(Street, City, Zip)

Phone Semester/Year PE 1 (Intro to PE) completed____ ________________

Reason applying for program:

Organization:

I wish to meet the PE requirement through this alternative program. I understand that if I do not complete the necessary hours, documentation or reflection, I will either need to repeat the process or take a PE course for credit. I understand this process will fulfill a PE requirement but will not result in credit and that I must still earn 22 or 24 total credits to graduate. I understand that if space becomes available in my four-year schedule, I will take PE rather than TA, Early Dismissal, or Late Arrival.

Student Signature Date

I agree that my student may pursue this alternative program to meet the PE requirement. If the necessary hours, documentation or reflection are not completed, my student will be required to repeat the process or take a PE course for credit. I understand this process will fulfill a PE requirement but will not result in credit and that my student must still earn 22 or 24 total credits to graduate. I understand that if space becomes available in my student’s four-year schedule, he/she will take PE rather than TA, Early Dismissal, or Late Arrival. It is my responsibility to know the details of my student’s meetings including where, when, purpose and with whom.

Parent/Guardian Signature Date

Activity Supervisor Information

Name: Title:

Address

(Street, City, Zip)

Home Phone Work/Cell Phone

I agree to supervise this student in this alternative program. I will participate in the process and honestly document and approve all activities and/or hours the student participates in. I attest that I am not the parent, guardian or sibling of the student.

Supervisor Signature Date

I approve this student’s PE requirement plan. Terms of the plan must be completed by _______________

(Student has two weeks after season is completed to turn in the remainder of the paperwork requirements) (Date)

Physical Education Supervisor Signature: Date

Principal Signature: Date

To be completed at the end of the term

The student has met .5 credits of the PE requirement. (Circle One) The student has not earned actual credit.

Principal Signature Date

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Washington State Physical Education

Standards Checklist

The following document explains how each portion of the waiver process connects to a Washington State Physical Education learning standard.

Physical Education Standard 1: Students will demonstrate competency in a variety of motor skills and movement patterns. (Met by participating in your self-selected activity )

Physical Education Standard 2 : Students will apply knowledge of concepts, principles, strategies and tactics related to movement and performance. (Met by participating in your self-selected activity and Waiver 1: Individual Fitness Plan)

Physical Education Standard 3: Students will demonstrate the knowledge and skills to achieve and maintain a health-enhancing level of physical activity and fitness. (Met by Waiver 1: Individual Fitness Plan and Waiver 2: Fitness for a Lifetime program)

Physical Education Standard 4: Students will exhibit responsible personal and social behavior that respects self and others. (Met by participating in your self-selected activity)

Physical Education Standard 5: Students will recognize the value of physical activity for health, enjoyment, challenge, self-expression, and social interaction. (Met by participating in your self-selected activity and Waiver 2: Fitness for a Lifetime program)

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EVERETT SCHOOL DISTRICT

Alternative Program to Meet Physical Education Requirement

Log of Physical Activity

After participating in an activity, document the dates of the week, activity, and time spent in the activity for the week. This log must be returned to meet the Physical Education requirement. In one sport/activity season you must accumulate a minimum of 75 hours to meet a .5 PE requirement). In activities such as marching band, dance, etc., time spent in competitions or performances may be counted as all members are involved at all times. Directed athletics and activities must comply with parameters established by the Everett Public Schools' Risk Management pool. Certain hazardous activities are prohibited. The district has the right to reject any activity that is judged to be unsafe.

Dates of Week

Activity

Weekly Hours

Coach Initials

Dates of Week

Activity

Weekly Hours

Coach Initials

TOTAL HOURS

TOTAL HOURS

I verify that the hours of activity reported are accurate.

Student Signature:_____________________________________________ Date:_________

Parent/Guardian Signature: _____________________________________ Date:_________

Coach/Advisor Signature: _______________________________________ Date:_________

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PE Waiver 2: Cognitive Assessment

Fitness for a Lifetime Exercise Program Evaluation

The goal of this assignment is to broaden your knowledge of other exercise opportunities aside from the sport or activity you are participating in currently. You will be evaluating three self-selected local exercise programs that you think you would enjoy beyond your high school experience. If you will be living in a different location in the near future, do your research around that location. This search can be broad in nature. Maybe you want to learn karate, yoga, or dance. This can be any type of gym or exercise program that you think you would enjoy and want to continue with as a regular form of exercise.

Exercise Program 1:

Name of Gym or Exercise Program:________________________________________________

Location: _____________________________________________________________________

How far is it from you in miles?: __________________________________________________

What is the monthly cost? _______________________________________________________

Web Address:_________________________________________________________________

What type of barriers do you see with this exercise program that you think may prevent you from attending?________________________________________________________________

______________________________________________________________________________

What are the characteristics of the exercise program that you think would be enjoyable to you?

______________________________________________________________________________

If your exercise opportunity is a multi-purpose gym what classes are offered there that you think you would enjoy aside from simply weight training?

______________________________________________________________________________

Does the fitness activity provide opportunities for social interaction? Describe the type of social interaction you think would be at the location. Do you think this is an important element when evaluating and exercise program and why? ______________________________________________________________________________

______________________________________________________________________________

Exercise Program 2:

Name of Gym or Exercise Program:______________________________________________

Location: _____________________________________________________________________

How far is it from you in miles?: ___________________________________________________

What is the monthly cost? _______________________________________________________

Web Address:__________________________________________________________________

What type of barriers do you see with this exercise program that you think may prevent you from attending?________________________________________________________________

______________________________________________________________________________

What are the characteristics of the exercise program that you think would be enjoyable to you?

______________________________________________________________________________

If your exercise opportunity is a multi-purpose gym what classes are offered there that you think you would enjoy aside from simply weight training?

______________________________________________________________________________

Does the fitness activity provide opportunities for social interaction? Describe the type of social interaction you think would be at the location. ______________________________________________________________________________

______________________________________________________________________________

Exercise Program 3:

Name of Gym or Exercise Program:_________________________________________________

Location: ____________________________________________________________________

How far is it from you in miles?: ___________________________________________________

What is the monthly cost? ________________________________________________________

Web Address:_________________________________________________________________

What type of barriers do you see with this exercise program that you think may prevent you from attending?_________________________________________________________________

______________________________________________________________________________

What are the characteristics of the exercise program that you think would be enjoyable to you?

______________________________________________________________________________

If your exercise opportunity is a multi-purpose gym what classes are offered there that you think you would enjoy aside from simply weight training?

______________________________________________________________________________

Exercise Program Evaluation Continued:

Option A Practical Application: Call or stop by one of the exercise facilities you are interested in and see if they would be willing to let you come and observe or take a class. Introduce yourself and let them know you are doing an Everett School District Physical Education community outreach assignment. Communicate to them that one of your assignments is to find a fitness opportunity in your local area that you would like to take part in. In a typed written response describe your experience as a whole:

Option B Self-Reflection: In a typed written response, reflect on your high school athletic experience and how it will continue to be a part of your lifetime of physical activity. Give examples of ways you can participate in your activity or sport when leaving high school. Consider community exercise events as an option to continue your participation in your sport. If you are playing your sport in college include other ways you could find this activity if you were not a collegiate athlete.

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3.	Participate in directed athletics including community and school programs or participate in marching band or NJROTC.
4.	Activities with personal trainers or individual workouts DO NOT meet the definition of "Directed Athletics" as required by state law and cannot be used for this waiver program.

5.	Commitment from an adult coach (not a parent or guardian or other family member) to monitor your activity and verify such activity to meet the requirements.
6.	Non-School sponsored sports must provide practice/competition schedules.
7.	Documentation of 75 hours (0.5 credits) within two weeks of completion of designated sport/activity. Allowable hours include practice and competition/performance time only.

9.	Completion of the required cognitive assignments within the packet.


EVERETT SCHOOL DISTRICT
Application for Alternative Program to Meet Physical Education Requirement
Directed athletics and activities must comply with parameters established by the Everett Public Schools' Risk Management Pool. Certain hazardous activities are prohibited. The district has the right to reject any activity that is judged to be unsafe.

Dates of Week	Activity	Weekly Hours	Coach Initials	Dates of Week	Activity	Weekly Hours	Coach Initials

















	TOTAL HOURS				TOTAL HOURS