APPLICATION FOR EXTRA-CLASS ACTIVITY EXEMPTION
Name: ___________________________________________ Grade: ________ HR: ___ Date: ________
Class Period: ________________________________ Extra-Class Activity: ________________________
Sponsor: ___________________________________ Quarter Requested (Circle One) 1 2 3 4
Purpose of Exemption:
If permission is granted for my exemption from the regular Physical Education Program, I agree to assume all responsibilities connected with successfully completing the requirements of the extra-class activity.
Student’s Signature ____________________________________________
I give permission for my child to be excused from his/her regular Physical Education
class for the time specified to participate in the extra-class activity listed above.
Parent or Guardian’s Signature ____________________________________________
The above mentioned student is currently participating in the extra-class activity as stated
above and meets the standard for participation as set forth in the North Colonie Coaches
Handbook.
Sponsor’s Signature ____________________________________________
Permission Granted for Exemption From The Regular Physical Education Program
Request Denied ____________
Signed by Director of Physical Education: ____________________________________________
Date: ______________
COPY TO:
Guidance Department
Hall Office
Note: Prior exhibit, 5125.3 (b)