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DateΚΚ __________ |
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Number of Students |
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| CHOOSE ONE OF
THE FOLLOWING ACTIVITIES: |
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Physical Activity |
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Nutritional Activity |
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Type of Activity: |
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Type of Food: |
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Walking |
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Fruit |
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Jogging |
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Vegetable |
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Stretching |
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Candy |
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Other (Please describe) |
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Cake/Cupcake/Cookies |
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Other (Please describe) |
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Activity Time: |
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Activity Time: |
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0-5 minutes |
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0-10 minutes |
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5-10 minutes |
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10-20 minutes |
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10-15 minutes |
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20-30 minutes |
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Other (Please denote) |
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Other (Please denote) |
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| COMPLETE ALL
ITEMS BELOW: |
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Class Activity Used For: |
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Site of Activity: |
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Math |
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Classroom |
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English |
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Gym |
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Science |
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Outside |
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Social Studies |
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FCS Rm |
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Reading |
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Cafeteria |
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Health |
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Other (Please Describe) |
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Other/Special (Please
describe) |
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Resource Used: |
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Please Circle: |
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Book/Magazine |
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Name |
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Did this activity promote Wellness? |
YΚΚΚΚ N |
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Web Page |
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Address |
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Would you repeat this activity? |
YΚΚΚΚ N |
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Original Creation |
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Other (Please Describe) |
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Was the student's reaction positive? |
YΚΚΚΚ N |
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PLEASE: |
RETURN COMPLETED FORM TO NURSE'S OFFICE |
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_26533_image003.gif){kind=small}