SAMPLE
XYZ Charter
719
Fourth Street
Anytown, TX
555/555-1234
Agency
Agreement
By completing and signing this agreement, you agree to the
responsibilities listed on the previous page.
Activity ________________________
Instructor __________________________________
Name of Agency/Facility
________________________ Phone _______________________
Address
___________________________ City _____________State _____ Zip _________
Instructor
Education/Certification _____________________________________________
Instructor Signature
_______________________________ Date _____________________
The student must
participate in his/her activity, under professional supervision in accordance
with one of the following options.
Please indicate which option with an X.
1. ________XX-hour option: Olympic-level
participation and/or competition including a minimum of ___ hours per week
of highly intense, professional, supervised training. The training faculty, instructors, and activities
involved in the program must be approved by the Curriculum Director. Students qualifying and participating at this
level may be dismissed from school one period per day. Students dismissed may not miss any class
other than physical education.
2. _________XX-hour option: Private or
commercially-sponsored physical activities including those approved by the
Curriculum Director. Student
participation of at least ____ hours per week is required. Students accepted to participate at this
level may not be dismissed from any part of the regular school day. Indicate the beginning time, ending time, and
the nature of the activity. It is
imperative that this schedule be kept current at all times. In case of a change in schedule please notify
the appropriate administrator at (xxx) xxx-xxxx
Beginning Time Ending Time Activity # Hours
MONDAY ___________ ____________ ____________ ___________
TUESDAY ___________ ____________ ____________ ___________
WEDNESDAY ___________ ____________
____________ ___________
THURSDAY ___________ ____________ ____________ ___________ FRIDAY
___________ ____________ ____________ ___________
SATURDAY ___________ ____________ ____________ ___________
SUNDAY ___________ ____________ ____________ ___________ TOTAL HOURS:
__________
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