Instructor Renewal Report Form

Please complete the form below to maintain your Physical Best Instructor certification.

Current NASPE/AAHPERD membership is required. Membership status will be checked as part of the certification renewal process.

First Name:
Last Name:
Street Address:
City:
State:
Zip/Postal Code:
Phone:
Email:
In the past five-year certification period, you must have completed a minimum of 5 activities total from the categories listed below. One or more of these activities must be either a Specialist workshop or a Specialist certification through a higher education course. Please list your 5 activities in the appropriate categories provided. (you do not need to list more than 5 activities TOTAL).

Specialist (workshop and/or higher ed course)
1:	mm/dd/yy
Location 1:
2:	mm/dd/yy
Location 2:
3:	mm/dd/yy
Location 3:
4:	mm/dd/yy
Location 4:
5:	mm/dd/yy
Location 5:

Half or Full Day In-service or Instructor Workshop

1:	mm/dd/yy
Workshop Title & Location 1:
2:	mm/dd/yy
Workshop Title & Location 2:
3:	mm/dd/yy
Workshop Title & Location 3:
4:	mm/dd/yy
Workshop Title & Location 4:
5:	mm/dd/yy
Workshop Title & Location 5:

One Hour Informational Session

1:	mm/dd/yy
Session Title & Location 1:
2:	mm/dd/yy
Session Title & Location 2:
3:	mm/dd/yy
Session Title & Location 3:
4:	mm/dd/yy
Session Title & Location 4:
5:	mm/dd/yy
Session Title & Location 5:

Published Educational Material on Physical Best

1:	mm/dd/yy
Name of Publication:
	Must be a peer-reviewed publication or listed as a contributor for a Physical Best book
2:	mm/dd/yy
Name of Publication:
	Must be a peer-reviewed publication or listed as a contributor for a Physical Best book
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