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| Question | Answer |
|---|---|
| Form Name | Wwe Application Form |
| Form Length | 3 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 45 sec |
| Other names | wwe application form 2020, wwe application form, wwe form, wwe joining application form |
Leader Workshop
Application Form
Date of Training: May 23, 2012 Location: Department of Disabilities and Special Needs,
3440 Harden St. Extension, Room 251, Columbia, SC 29203
Applications due by May 16, 2012
COMPLETE ALL SECTIONS. TYPE OR PRINT NEATLY.
Today’s Date: _________________________
CONTACT INFORMATION
First Name: |
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For Arthritis Foundation correspondence, please contact me at: My worksite (if applicable) |
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FACILITY INFORMATION
Please provide information about the host facility where you plan to conduct the Arthritis Foundation Walk with Ease Program classes (if different from your job location):
Facility Name:
Address:
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Administrator/ Contact Person Name: |
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Does the location where you plan to teach have a signed Program
YES |
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QUALIFICATIONS *Attach copy of card
Do you have current ADULT CPR certification? (Required) |
YES* |
NO |
Do you have current First Aid certification (Recommended) |
YES* |
NO |
List other relevant certifications and their expiration date: |
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EXPERIENCE
What professional or volunteer experience have you had leading exercise classes, conducting workshops or speaking in public?
What is your profession and/or background in health, fitness or education? List any relevant degrees or course work.
What other experience do you have that you feel would be beneficial in leading AF programs (such as work with people with disabilities, older adults, people with special needs)?
What is your experience with arthritis (personal or family member diagnosis, or work with people with arthritis)?
Why do you want to teach the Arthritis Foundation Walk with Ease Program? What benefits would you like to gain from leading this program?
How did you become aware of the Arthritis Foundation Walk with Ease Program?
Have you been a participant or leader/ instructor in any other Arthritis Foundation program and if so, please list:
FEE INFORMATION
Please charge |
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Please send complete application, payment and |
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attached SIGNED Statement of Understanding to: |
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to my |
AMEX |
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Card #: ______________________________________ |
SC DHEC |
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Pat Williams |
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Expires: ______________________________________ |
Box 101106, Mills/Jarrett Bldg. |
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Name on Card: ________________________________ |
Columbia, SC 29211 |
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Signature: ____________________________________ |
Phone: (803) |
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Please make checks payable to: Arthritis Foundation |
Fax: (803) |
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Registration Fee is $25 |
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Statement of Understanding
The Arthritis Foundation has established the following policies and procedures to ensure the quality of its programs. Please sign below to indicate your acknowledgement and acceptance of these requirements:
I will conduct an Arthritis Foundation WALK WITH EASE Program six‐week group walk within three months of completing the WALK WITH EASE training workshop and a second walk within twelve months of the training. I agree to conduct walks twice annually thereafter.
I understand that AF certification provides me with a limited license to deliver the WALK WITH EASE program as long as I maintain my affiliation with the Arthritis Foundation and uphold its policies and procedures. I acknowledge that the program materials are copyrighted and agree to honor the program’s copyright protection.
I agree to follow the standardized program curriculum and will not make any variations in the approved program content or process described in the Leader’s Guide without prior written permission.
I understand the AF liability insurance only covers me when I offer AF classes at sites that have a signed Program Co‐sponsorship Agreement on file with the AF documenting their compliance with AF policies and their acceptability as host sites, including adequate insurance coverage and accessibility to people with disabilities. I agree to notify the AF if I stop teaching the AF program at the approved site or if my teaching status changes.
I will conduct and support marketing efforts for the AF classes in my community in collaboration with the AF
and DHEC. I will notify DHEC well in advance of each walk to assure adequate time for promotion and other preparations. I will assure that participants recognize the AF’s co‐sponsorship of the classes. I will provide participants with information about other AF programs and services.
To protect the AF and the host facility against legal claims, I will secure Participant Release Forms from all new course participants and will submit these forms to the AF.
I will submit complete and timely participant data and participate in any other data collection projects that the Arthritis Foundation uses to measure the reach, quality and/or impact of the Walk with Ease Program in accordance with a specified reporting schedule and method.
I agree to uphold and maintain the policies, procedures, standards and curriculum of the WALK WITH EASE Program and to not make any variations in the approved program content or process without prior written permission. I also agree to fulfill all obligations listed in the WALK WITH EASE Leader Position Description and Leader’s Guide.
I understand that the Arthritis Foundation is a voluntary health organization. If serving in a voluntary capacity, I understand that I am not entitled to receive compensation or employee benefits from the Arthritis Foundation.
I HAVE READ AND I UNDERSTAND THE PRECEDING STATEMENTS. I FURTHER UNDERSTAND THAT COMPLIANCE WITH THIS STATEMENT OF UNDERSTANDING IS REQUIRED FOR MY TRAINING AND CONTINUED PARTICIPATION AS AN ARTHRITIS FOUNDATION WALK WITH EASE LEADER.
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Print Name of Leader Applicant |
Date |
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Signature |
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