Mission Public Schools

Graduation Planning 12
Confirmation of Physical Activity
(can be a team, club or individual)

I would like to confirm that ___________________________ has completed _____ hours of

Moderate to Intense physical activity.
Club/Team or Organization name: ________________________________________
The type of physical activity was: ______________________________________________
____________________________________________________________________
____________________________________________________________________
The activity was completed on, or between the following dates: ___________-___________
Name of Teacher / Coach or Supervising adult: _______________________ (print clearly)
Contact Phone number(s) of supervisor: ____________________ or ___________________
Performance comments (optional): ______________________________________________
____________________________________________________________________
____________________________________________________________________

Signature: _______________________________

Date: ________________________