AMSEA - Course Reporting Form

To help us monitor the effectiveness of our programs, we request that you furnish AMSEA with information after the completion of each cold water safety course, workshop or seminar you teach. AMSEA also uses the information for quarterly activity reports, funding proposals, program justification, and to serve you better.

Fill in the blanks below and click the submit button to send it to us. Click the reset button to clear the form for the next entry. Please be specific in your answers.

Instructor Information

Primary Instructor Name:

Primary Instructor E-mail Address:

Primary Instructor Phone:

Additional Instructor Name(s): (enter NA if none)

Course Information

Dates: (mm/dd/yyyy)
Start: End:

City where the course was held:

Name of the organization, school, business or other group for which you provided this course:

State:

Country:

Length of Course (total hours):

Course Name or Type (choose one):

Fishermen's Workshop
AK Water Wise (AWW) only
Expanded course for rec boaters that included AWW
Emergency Procedures for Recreational Boaters (EPRB)
Other course for recreational or subsistence boaters
Course for children
Course for children & parents or other adults
Custom course for adults associated with an organization, government agency, or business

Course Partcipant Information

Number of partcipants over age 18 :
Number of partcipants age 18 and under :

Check the box(es) that best describe the participants:

Approximate ages of children participating in your course:
(check all that apply)

AMSEA Course Reporting Form

Instructor Information

Course Information

Course Partcipant Information

Additional Information