To register online, fill in the blanks below and click the submit button at the bottom of the form to send it to AMSEA. Please be specific in your answers. This form has five sections that must be filled out completely, with some optional information at the bottom.

If you prefer to mail or fax your registration to AMSEA, you may download a printable MSIT registration form.

* = required field

If you don't have one of the required pieces of information, enter "N/A" in the field. Blank required fields will cause the form to reject your submission.

Section 1:
Your Contact Information

If you don't have one of the required pieces of information, enter "N/A" in the field. Blank required fields will cause the form to reject your submission.

*Full Name:

*Mailing Address:

*City:

  *State:   *Zip:

*E-mail Address:

*Daytime Phone:

*Evening Phone:

*Fax:

Section 2:
Course Location, Dates, and Components

*Course location:

Sitka, Alaska
Seward, Alaska
Other city and state (enter below)

*Course begin date:

*Amount(s) you are to be billed :

You will be contacted regarding payment arrangements.

AMSEA member price*...............................................  $495.00
Nonmember price .....................................................  $550.00

Optional Add-On:

Standards for Training Certification and Watchkeeping (STCW) Train the Trainer........................................................................  $200.00

*To learn about AMSEA membership, please click here.

Section 3:
Reference Information

Please indicate one reference who is familiar with your background.

*Name:

*Mailing Address:

*City:

*State: *Zip:

*Daytime Phone:

*E-mail:

Section 4:
Emergency Contact Information

Please indicate one reference who is familiar with your background.

*Name:

*Relationship to you:

*Daytime Phone:

*Evening Phone:

*E-mail:

Section 5:
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, Physician? If yes, state the level of training and expiration date.

     No CPR/First Aid Training CPR/First Aid Provider Emergency Trauma Tech Emergency Medical Tech Paramedic Nurse Physician's Assistant Physician         expiration: N/A Expired 2003 2004 2005 2006 2007 2008 2009 2010

*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, location and general subjects covered.

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

    No           Yes

*6. Indicate approximately how many pool lengths you can swim. (Ability to swim is not a course pre-requisite.)

    0 1 2 3 4+  

*7. Are there any health or physical considerations that might prevent you from participating in a pool exercise, an overnight survival exercise or other vigorous physical activity? If so, please describe so instructors can make appropriate accommodations. (Answer is required; enter "N/A" if you need no special considerations.)

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

*9. If you will be teaching safety as part of your job, approximately what percentage of your time will you spend on planning and instruction of marine, water and boating safety? (Required. Enter "N/A" if not applicable.)

Optional information:

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

Name:

Mailing Address:

City:

State: Zip:

Daytime Phone:

E-mail:

Comments or questions:

STOP!

If you don't have one of the required pieces of information, enter "N/A" in the field. Blank required fields will cause the form to reject your submission.