RIAHPERD Award Application

Send completed application to: Dr. Cathy Moffitt: cgmof@hotmail.com. Return this form no later than October 16, 2011

Applicant Name:      

Home Address: Street: 

                  City/Town: 

              State and Zip:

Present Position/Title:  

School Name:

Street Address:

City/Town:

State and Zip:   

RIAHPERD Membership #:     

Bachelor/Master/Doctoral Degree (Year and Degree):

Career Information:

Position:   

Location:  

Length of Service:  

Position:   

Location:   

Length of Service:  

Position:   

Location:   

Length of Service:  

Position:   

Location:   

Length of Service:  

Position:   

Location:   

Length of Service:  

Below please limit text to the space provided.  

Professional Affiliations: (AAHPERD, NASPE, AAHE, etc.)

AAHPERD Membership #:      

RIAHPERD Offices:

Committees:

Project Involvement: (HealthFit Expo, RI Healthy Schools Coalition, AHA Jump/ Hoops for Heart, etc.)

School or District Committees/Offices, etc.:

Other Professional Affiliations   

Project Involvement:     

Significant Achievements in the Fields of Health, Physical Education, Recreation and Dance:     

Community Service: