REQUEST

 

FOR

 

ASSISTANCE

 

WITH

 

PHYSICAL

 

EDUCATION

 

 

Student:_________________________________________

  

DOB:_______________________________

 

School:__________________________________________

  

Grade:______________________________

 

Person

 

Completing

 

Request:_________________________

  

Date

 

of

 

Request:______________________

 

P.E.

 

Teacher:_____________________________________

 

 

Parent

 

Name:____________________________________

  

Phone:______________________________

 

Address:___________________________________________________________________________________

 

 

Please

 

provide

 

a

 

description

 

of

 

your

 

specific

 

concerns

 

regarding

 

this

 

request:

 

__________________________________________________________________________________________

 

__________________________________________________________________________________________

 

__________________________________________________________________________________________

 

__________________________________________________________________________________________

 

__________________________________________________________________________________________

 

 

How

 

would

 

you

 

describe

 

the

 

student’s

 

ability

 

to:

1 Inadequate

  

2

 

Poor

  

3

 

Fair

  

4

 

Good

  

5

 

Excellent

 

 

a. Walk

  

 

1

    

2

    

3

    

4

    

5

 

b. Skip

  

 

1

    

2

    

3

    

4

    

5

 

c. Gallop

  

 

1

    

2

    

3

    

4

    

5

 

d. Run

  

 

1

    

2

    

3

    

4

    

5

 

e. Throw

  

 

1

    

2

    

3

    

4

    

5

 

 

 

f. Catch

     

1

    

2

    

3

    

4

    

5

 

g. Roll

 

a

 

Ball

  

 

1

    

2

    

3

    

4

    

5

 

h. Hit

 

a

 

Ball

  

 

1

    

2

    

3

    

4

    

5

 

i. Kick

 

a

 

Ball

  

 

1

    

2

    

3

    

4

    

5

 

 

 

How

 

would

 

you

 

describe

 

their:

 

 

a. Behavior

  

 

1

    

2

    

3

    

4

    

5

 

b. Peer

 

Relations

  

 

1

    

2

    

3

    

4

    

5

 

c. Cognitive

 

Understanding

 

of

 

Activities

 

 

                                        

1

    

2

    

3

    

4

    

5

 

d. Overall

 

Eye

‐

Hand

 

Coordination

 

 

      

 

                                        

1

    

2

    

3

    

4

    

5

 

 

e. Overall

 

Eye

‐

Foot

 

Coordination

  

 

                                        

1

    

2

    

3

    

4

    

5

 

f. Vision

     

1

    

2

    

3

    

4

    

5

 

g. Hearing

  

 

1

    

2

    

3

    

4

    

5

 

 

 

Any

 

other

 

information

 

that

 

you

 

feel

 

the

 

APE

 

needs

 

to

 

know:

 

__________________________________________________________________________________________

 

__________________________________________________________________________________________

 

__________________________________________________________________________________________

 

__________________________________________________________________________________________

 

 

Do

 

you

 

feel

 

the

 

student

 

has

 

health

 

concerns

 

that

 

need

 

addressed

 

and

 

if

 

so

 

what

 

are

 

they?

 

__________________________________________________________________________________________

 

__________________________________________________________________________________________

 

__________________________________________________________________________________________

 

 

Please

 

send

 

a

 

copy

 

of

 

the

 

request

 

to

 

the

 

school

 

psychologist

 

and

 

the

 

adapted

 

physical

 

education

 

teacher.