To register online, fill in the fileds below and click the submit button at the bottom of the page. Please be specific in your answers. This form has five sections that must be filled out completely. There is an optional section where you can refer a friend to the training.

After completing this registration form online, you will be contacted regarding payment and other pre-course requirements.

If you wish to apply via hard copy, you may access an application here: 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: Course Location, Dates, and Components

*Course location:

Sitka, AK: October 15 - 21, 2013
Other city and state (enter below)

*Amount(s) you are to be billed :

You will be contacted regarding payment arrangements.

AMSEA member price*...........................................  $875.00
Nonmember price .................................................  $995.00
Requesting Scholarship.......................................... $ Varies
Limited scholarships may be available for individuals meeting certain criteria. See the application for more information and to apply.

Refresher training is only available to persons who have previously completed the basic, 6 day Marine Safety Instructor Training. Refresher course does not include books or other materials.

*To learn about AMSEA membership, please click here.

Optional Add-On – Standards for Training Certification and Watchkeeping (STCW) Train-the-Trainer

STCW Train-the-Trainer certification is designed for higher tonnage U.S. Coast Guard licensed mariners who work on international voyages and are in a position to conduct training for these vessels. It involves additional study and taking an additional written test. The standard AMSEA Coast Guard-accepted MSIT course will meet the requirements of most trainers.

STCW Train-the-Trainer...............................................  $200.00

Section 2: 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 3: References

Please indicate one reference who is familiar with your background.

*Name:

*Mailing Address:

*City:

*State: *Zip:

*Daytime Phone:

*E-mail:

Section 4: Emergency Contact

Please provide the name of a person you wish us to contact on your behalf in the case of an emergency.

*Name:

*Relationship to you:

*Daytime Phone:

*Evening Phone:

*E-mail:

Section 5: Additional Information

*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 2009 2010 2011 2012 2013 2014 2015 2016

*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. Boating experience:

*How many years of boating experience do you have?

    Please select None Less than 2 2 to 5 5 to 10 More than 10

*What types of boating experience do you have? (Check all that apply.)

None

Commercial fishing

Small power boats - skiffs

Paddle boats such as kayaks or canoes

Larger recreational power boats, cruisers, yachts

Sailing

Operating charters or other passenger vessels

Operating tugs or other large commercial vessels

Other boating experience (please describe):

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

    Please select None 1 2 3 4+

*8. 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.)

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

*10. 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: Refer a Friend!

Do you know anyone who may be interested in this or future Commercial Fishing Vessel Safety Instructor 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.