REQUEST FOR RECOGNITION OF BICYCLE PROGRAM TEACHING EXPERIENCE

This form should be used by teachers and other school support personnel who wish to gain reaccreditation by completing the Bicycle Education refresher training course and who have been:

· accredited in Bicycle Education (Bike Ed or Cycle On) training more than 5 years ago AND

· teaching and providing practical training for students in Bicycle Education in an ongoing  way                                                   since gaining accreditation.

        NB. If the original training was before 1996, a copy of the certificate of training or a letter from VicRoads                                                         road safety staff, stating place and date of training, must accompany this form.

(If handwritten please print clearly)

 

 

Office / Organisation / School:………………………………………………………………………

 

Full Name and Title of Person: ……………………………………………………………………

(for whom recognition of experience is being sought)

Contact details: Ph………………………………….. Fax:…………………………………………

 

Email …………………………………………………………………………………………………

Details of previous Bicycle Education instructor accreditation training:

 

Trainer’s Name:…………………………Location:…………………………Year:……………

Has the person applying for reaccreditation

been teaching and providing practical

training for students in Bicycle Education

continuously for the past five years?

 

             YES                   NO

             (Circle the appropriate response)

 (If Yes, go directly to declaration section below)

  (If No, please complete the adjacent details as

   far as possible )

Please provide available information about the period(s) and level(s) in which the person applying for reaccreditation has been teaching and providing practical training for students in Bicycle Education:

 

DECLARATION

I, ……………………………………………… of …………………………………… declare that

         (Applicant’s name)                                                                           (School/Organisation name)

to the best of my knowledge the information contained in this document is true, complete and correct.

Signature of applicant  …………………………………………………… Date…………………………….

PRINCIPAL’S ENDORSEMENT

Principal’s name ……………………………………………………….

 

Signature of Principal: …………………………………………………………….. Date: ..……………………….…

Approval to complete Refresher Course for Bicycle Education .

This section to be completed by the Department of Education & Training Officer responsible for managing the Bicycle Education Instructor Training for Teachers and other school support personnel, or by current Department of Education & Training preferred provider of that training.

Officer’s name: (please print) ………………………………………… Officer’s title: ……………………………….

Signature: …………………………………………………………………………… Date. ……………………………….