Fill in the blanks below and click the submit button to send it to AMSEA. Please be specific in all your answers. You may click the reset button to clear the form.

Your name:

Mailing Address: City State Zip

E-mail Address:

Daytime Phone: Evening Phone: Fax:

AWW Instructor course location as listed on AMSEA's Course Schedule: Course date:

Please complete the following questions.

1. Why do you want to take this class and what do you hope to learn from it?

2. Have you ever been a certified CPR provider, First Aid provider, Emergency Trauma Technician, Emergency Medical Technician, Paramedic, Nurse, or Physician? If yes, state the level of training and expiration date.

3. Have you ever taken any methods of instruction courses? If so, when and where? Indicate if you have an education degree or teaching certificate.

4. Have you ever taken or taught a survival course or safe boating course? If so, please note the year taken, location and general subjects covered.

5. Have you ever had a friend or relative who was a drowning or boating accident victim?

6. Can you swim? If so, indicate approximately how many pool lengths you can swim. (Ability to swim is not a course pre-requisite.)

7. Are there any health or physical considerations that might prevent you from participating in the pool exercise, an overnight practical or other vigorous physical activity? If so, please describe so instructors can make appropriate accommodations.

8. Please indicate one reference who is familiar with your background.

Name

Mailing Address: City State Zip

Daytime Phone:

9. Do you know of anyone who may be interested in this or future instructor courses? If so, please provide their contact information.

Name

Mailing Address: City State Zip

Daytime Phone:

10. Who do you plan to instruct in marine safety and in what locations of the state, nation or world will this training take place?

11. If you will be teaching safety as part of your job, approximately what percentage of your time will you be spending on planning and instruction of marine, water and boating safety?

Comments or questions: