ILLINOIS STATE UNIVERSITY

SCHOOL OF KINESIOLOGY AND RECREATION

Graduate Teaching Assistant Preferences

Full Name: / Student ID Number: / Date:
Local Address: / Local Phone:
E-mail Address: / Sequence / Anticipated Graduation Date:

Rank the Activities as follows: Put an “X” (1) to indicate ALL activities which you are well qualified to teach.

(2) to indicate all others which you are adequately qualified and could teach.

(3) to indicate you have limited experience but could teach if guidance were given.

COURSE / RANK / COACHING EXPERIENCE
Describe below:
Adventure Education / 1 / 2 / 3
Aerobics / 1 / 2 / 3
Aerobic Instructor Certification
Expiration Date:
Aerobic Instructor Certifying Agency:
Aquatic Fitness / 1 / 2 / 3
Badminton I (Beginning) / 1 / 2 / 3
Basketball II (Intermediate) / 1 / 2 / 3
Billiards I (Pocket)(Beginning) / 1 / 2 / 3
Billiards II (Pocket)(Intermediate) / 1 / 2 / 3
Bowling I (Beginning) / 1 / 2 / 3
Bowling II (Intermediate) / 1 / 2 / 3
First Aid/CPR / 1 / 2 / 3
First Aid Certification Expir. Date:
First Aid Certifying Agency:
First Aid Instructor Certification
Expiration Date:
First Aid Instructor Certifying Agency:
CPR. Certification Expir. Date:
CPR. Certifying Agency:
CPR Instructor Certification
Expiration Date:
CPR Instructor Certifying Agency:
/ SPORTS PARTICIPATION
Describe below:
Fitness & Conditioning/Walk-Jog-Run / 1 / 2 / 3
Golf I (Beginning) / 1 / 2 / 3
Golf II (Intermediate) / 1 / 2 / 3
Nautilus Conditioning/Weight Training / 1 / 2 / 3
Soccer / 1 / 2 / 3
Slo-Pitch Softball / 1 / 2 / 3
Swimming I (Beg) WSI Req / 1 / 2 / 3
Swimming II (Inter) WSI Req / 1 / 2 / 3
Water Safety Instructor Certification
Expiration Date: / 1 / 2 / 3
Water Safety Instructor Certifying Agency:
Tennis I (Beginning) / 1 / 2 / 3
Volleyball I (Beginning) / 1 / 2 / 3
Volleyball II (Intermediate) / 1 / 2 / 3
Other / 1 / 2 / 3
1 / 2 / 3
1 / 2 / 3
ACE Certification Expir. Date:
Fitness Certification Expir. Date:
Fitness Certifying Agency:
NATA Certification Expir. Date:

NOTE: Please share any other pertinent information that will enable us to make appropriate assignments and/or know you better. Use other side if necessary.