PHIT America Program Application

Application for PHIT America programs

PLEASE NOTE: AMPED Running/Walking Program must be awarded prior to receiving grants and equipment for PHIT America sports programs. Sports program curriculum, training and equipment is free to qualifying schools while supplies last with funds provided to pay the Play Tennis or Play Golf Champion to run the program
PHIT AMERICA AMPED - RUNNING/WALKING PROGRAM (includes Kit/EZ Scan)

Yes, I want to apply for the AMPED Running/Walking Program
PHIT AMERICA PLAY Tennis program (equipment provided by USTA)

Yes, please consider my application for the PLAY Tennis program (check if interested)
PLAY Golf program (equipment provided by Payne Stewart Kids Golf Foundation)

Yes, please consider my application for the PLAY Golf program (check if interested)
SECTION I: Application for AMPED Running/Walking Program
CONTACT INFO: Name of person completing the application

I will also be the person (AMPED CHAMPION) conducting the AMPED Program
Name*

Contact First NameContact Last Name
Phone Number*
Please enter a valid phone number.
Your Work Email*
example@example.com
Your Personal Email*
Please provide a personal email in case your work email will not allow our emails through
Your Role*
SCHOOL DISTRICT INFORMATION
School Name *
Name of School where programs will be held
School District*
Full name of the school district your school is a part of
School District Website
http://website name
School Shipping Address to send AMPED Kit and program equipment*

Street Address

Street Address Line 2

CityState

Zip Code
Main Phone Number*
Please enter a valid phone number.
Type of School*
Principal's Name*

Principal's First NamePrincipal's Last Name
Principal's Email*
example@example.com
Student Enrollment*
Total number of student's enrolled for current school year.
# of boys enrolled*
Number of students who are boys.
# of girls enrolled*
Number of students who are girls.
% of students on Free/Reduced Lunch*
What percent of students at your school are on Free or Reduced Lunch?
Will ALL students have access to AMPED?*
Is your School Signed up with Active Schools?*
AMPED Champion for the School

Only complete, If this will be someone other than yourself
Person Implementing the AMPED Running/Walking Program

AMPED Champion FIRST NAMEAMPED Champion LAST NAME
Your Role
Champion's phone
Please enter a valid phone number.
Champion's work email
example@example.com
Champion's personal email
In case our emails bounce due to district restrictions to work/school emails. Please provide a personal or secondary email so we can effectively communicate.
APPLICATION QUESTIONS (required section)

Please complete the following section
Why should your school be awarded AMPED?*
In 500 characters or less, please describe why your school should be awarded AMPED. Include how you will use this program, why you feel it is important for your school, and what impact you think it will make at your school.
Commitment to Program*
In 500 characters or less, please describe your school's philosophy around physical activity and what type of commitment your school has to implementing this type of programming. Include who is behind this program, what staff has offered to help and support this type of program, what type of funding does your school spend on physical activity.
Does your school have a dedicated PE Teacher?*
How often per week are kids getting PE at your school?*
On average, how many days per week is each student getting PE
Are you currently holding a running program at your school?*
When do you plan to start running the AMPED program?*
Please provide a timeframe for when you will start AMPED at your school? (ie. Fall, Spring, next year)
What time of day will you run AMPED?*

Select AllBefore SchoolRecessLunchAfter-schoolDuring the day as breaks
How many days a week do you plan to run AMPED?*
How many weeks a year do you plan to run AMPED?*
How did you hear about AMPED Program?
Application for Sport Programs

Before, During or After-school Programs for Tennis and/or Golf - The following questionnaire will help us determine your application in providing free grants to your school for programs and equipment. NOTE: AMPED Program approval required. There are a limited number of tennis and golf programs/equipment available.
Does your School currently have the following: (check all that apply)

AMPED Running/Walking ProgramAfter-school programsDedicated PE TeacherUSTA youth tennis (Net Generation) provided instruction/equipmentAssociation with local tennis coach or programNearby tennis courts or park/rec areaSchool District tennis program and/or team
Name of Person Interested to Conduct the PHIT America PLAY TENNIS Program

Play Tennis Champion FIRST NAMEPlay Tennis Champion LAST NAME
Email
example@example.com
Phone Number
Please enter a valid phone number.
Does your School currently have the following: (check all that apply)

AMPED Running/Walking ProgramAfter-school programsDedicated PE TeacherAssociation with local golf coach or programNearby golf course or driving range?School District golf program and/or teamPrior exposure to school golf programs - i.e. First Tee
Name of Person Interested to Conduct the PHIT America PLAY GOLF Program

Play Golf Champion FIRST NAMEPlay Golf Champion LAST NAME
Email
example@example.com
Phone Number
Please enter a valid phone number.
Use this space to provide any added information, questions or comments:
THANK YOU FOR YOUR SUBMITTING YOUR APPLICATION!

We will review and notify you within 2-4 weeks of the status of your approval.
Please visit phitamerica.org for more information or email amped@phitamerica.org.
Should be Empty:

Application for PHIT America programs

SECTION I: Application for AMPED Running/Walking Program

SCHOOL DISTRICT INFORMATION

AMPED Champion for the School

APPLICATION QUESTIONS (required section)

Application for Sport Programs