Prepared by Linda Geyer-Personal Trainer

PREBENCHMARK

EXERCISE-LINDA

DISTRIBUTE-MARCH 2

COMPLETE-END OF SESSION MARCH 9

NAME-

DATE OF BIRTH -

SCHOOL-OAKLAND/UPTON/OTHER-

CHIPS Posttest Exercise

1.        How many hours do you spend watching TV, in front of computers, or playing video games or game boys per week between March 2-9, 2005?  ______________

2.        How many times during the week from March 2-9, 2005 do you get physical activity or exercise?  ___________

What is the duration of your physical activity during the above week?  __________ minutes

3.        Do you play any sports either individual or team during the above week?  ___________

Exercise Challenge

Spend a minimum of 30 minutes every day in some form of physical activity/exercise.  Physical activities includes:  walking, jogging, running, bike riding, jump rope, sporting activities such as soccer, volleyball, hockey, dodge ball.

Jump rope challenge increase the number of jumps and time.

ONCE COMPLETE PLEASE:

CHILD SIGNATURE AND INITIAL-

PARENT SIGNATURE AND INITIAL-

INSTRUCTOR SIGNATURE AND INITIAL-

SUPERVISOR SIGNATURE AND INITIAL-

TICKET GIVEN TO PARTICIPANT FOR COMPLETION-Y/N

REMEMBER , WE ARE LOOKING FOR IMPROVEMENT TIME TO TIME AND THE ABILITY TO APPLY WHAT YOU LEARN TO YOUR DAILY LIFE.  WE INTEND THIS TO BE COMPLETELY NONJUDGEMENTAL AND NONTHREATENING FOR THE CHILDREN.  THE ONLY PERSON YOU ARE COMPETING AGAINST IS YOURSELF! GOOD LUCK-HAVE FUN!!

THANK YOU,

YOUR CHIPS TEAM