Student Name (print) ___________________________________________
Grade _______
I honestly completed all of
the activities checked on the back of this form. I have attached
any non-physical activity assignments to this sheet.
Student Signature ______________________________________________ Date ________
Parent Information - Parent Name
(print) ________________________________________
My child has my permission to
participate in this HomeWORKOUT Challenge.
Parent Signature _______________________________________________
Date ________
I will sign the back of this
sheet AFTER my child has truthfully completed the checked activities on
the back of this form.
| FREQUENCY | INTENSITY | TYPE | TIME |
| Adult Initials/Date | Circle One | Activity Description | Minutes/Reps to complete |
| 1)__________2)__________ | Easy Moderate Hard Easy Moderate Hard | Dribble Soccer Ball | 20 minutes |
| 1)__________2)__________ | Easy Moderate Hard Easy Moderate Hard | Shoot Hoops | 20 minutes |
| 1)__________2)__________ | Easy Moderate Hard Easy Moderate Hard | Move to Music | 15 minutes |
| 1)__________2)__________ | Easy Moderate Hard Easy Moderate Hard | Sweep the driveway or garage or sidewalk or basement or porch | 15 minutes |
| 1)__________2)__________ | Easy Moderate Hard Easy Moderate Hard | Walk with FamilyMember(s) | 20 minutes |
| 1)__________2)__________ | Easy Moderate Hard Easy Moderate Hard | Play Hopscotch | 15 minutes |
| 1)__________2)__________ | Easy Moderate Hard Easy Moderate Hard | Ride a bike | 15 minutes |
| 1)__________2)__________ | Easy Moderate Hard Easy Moderate Hard | Hula Hoop | 15 minutes |
| 1)__________2)__________ | Easy Moderate Hard Easy Moderate Hard | Jump Rope | 15 minutes |
| 1)__________2)__________ | Easy Moderate Hard Easy Moderate Hard | Throw a ball with a Friend | 20 minutes |
| 1)__________2)__________ | Easy Moderate Hard Easy Moderate Hard | Walk/Jog/Run | 15 minutes |
| 1)__________2)__________ | Easy Moderate Hard Easy Moderate Hard | Kick a ball with someoneOlder | 15 minutes |
| 1)__________2)__________ | Easy Moderate Hard Easy Moderate Hard | Kick a ball with someoneYounger | 10 minutes |
| 1)__________2)__________ | Easy Moderate Hard Easy Moderate Hard | Formal Sport practice or Game | Sport __________
Minutes _______ |
| 1)__________2)__________ | Easy Moderate Hard Easy Moderate Hard | Aerobic stepping or Exercise tape | 30 minutes |
| 1)__________2)__________ | Easy Moderate Hard Easy Moderate Hard | Pushups/jog steps/Crunches | 10 reps, 4 sets |
| 1)__________2)__________ | Easy Moderate Hard Easy Moderate Hard | Free Choice _________________ | 20 minutes |
| 1)__________2)__________ | Easy Moderate Hard Easy Moderate Hard | Skate/blade/board
(circle one) |
20 minutes |
| 1)__________2)__________ | Easy Moderate Hard Easy Moderate Hard | Basketball ball handlingDrills | 15 minutes |
| 1)____________________ | Eat 5 servings of fruit/veg. 3 days in a row. | Make a list and attach | |
| 1)____________________ | Chore __________________ | Do any household chore without being asked | 10 – 15 minutes |
| 1)____________________ | List at least 5 things you are thankful for. | Make a list and attach | |
| 1)____________________ | Drink 8 glasses (8 oz) of water 3 days in a row. | Dates ___________________ |
I verify that my child has completed the initialed activities.
Parent Signature ___________________________________________________________ Date__________________