Ron Rhinehart International Aquatic Safety School Candidate Application

NOTE: All fields marked with a red * are required for submission

Section 1: Personal Information
*
Middle Initial:
*
Address: *
City: *
State: *
Zip Code: *
Business Phone: *
Fax: *
Home Phone: *
Email Address: *
Gender: *
Shirt Size: *

Section 2: Emergency Information
Emergency Contact: *
Relationship: *
Emergency Phone #: *

Section 3: Client Information
Current Employer (Client Name): *
Position: *
Current Employer's Address: *
City: *
State: *
Zip Code: *
Select your Facility Type: * Other

Section 4: Enrollment Information
1.) Have you been a lifeguard before? *
--If yes, through which provider
2.) Are you currently certified/licensed as a lifeguard? *
--If yes, through which provider
3.) Have you been a lifeguard instructor before? *
--If yes, through which provider
4.) Are you currently certified/licensed as a lifeguard instructor? *
--If yes, through which provider
5.) Have you had a CPR class within the last 2 years? *
6.) Have you attended IASS in the past? * If yes, how many times?
7.) Years of full time experience within the aquatic industry. *
8.) Did you attend IASS in 2008 *
-- If yes, which group were you in
9.) Which of the following best describes your goals/peer group for IASS in 2009? (Select from the list below:)*
Group 1 – Little to no experience lifeguarding/instructing – focus on the fundamentals of the lifeguard program as well as the basics of becoming an instructor and the fundamentals of the comprehensive program, maybe not an aquatics professional but someone from the organization looking to expand their knowledge base
Group 2 – Have been a lifeguard before but have never been to IASS or been an Instructor – focus on the basic aspects of being an instructor and also the basics of the comprehensive program, maybe not an aquatics professional but someone from the organization looking to expand their knowledge base
Group 3 – Have been a lifeguard before and have been an instructor but never to IASS – review training for being an instructor and first time experiencing IASS and all of its glory

Group 4 – Have been a lifeguard and an instructor and have been to IASS 1-3 times – review training for being an instructor and can begin to appreciate IASSS more the 2nd or 3rd time (like a movie where you don’t really get it until you’ve seen it several times, Usual Suspects for example)
Group 5 – Have been a lifeguard and an instructor and have been to IASS more than 3 times – very proficient in the aspects of the LG and Instructor Program, working towards becoming an IT, probably someone who is in a Operations Manager type of position
Group 6 – Have been to IASS more than 5 times – extremely  proficient in the LG and Instructor Program, some members are IT’s or faculty members from previous years

Section 5: Additional Instruction (Optional)
CPO Certification Course $250 – acquire your certification as a Certified Pool Operator (8-5 Sat and Sun)
Jeff Ellis Swimming New Coordinator $275 – acquire your license as a JES Coordinator (8-5 Sat and Sun)
Jeff Ellis Swimming Renewal Coordinator $225 – renew your license as a JES Coordinator (8-5 Sun)

Payment Information
Tuition: * Tuition Schedule and Discount Information
Bill Client Client Purchase Order - # Bill Credit Card Below
Credit Card Type:
Credit Card Number
Expiration Date(mm/yyyy)
Cardholder Name
CCV Number:
NOTE: CREDIT CARD INFORMTION WILL NOT BE PROCESSED ONLINE. IF YOU DO NOT RECIEVE AN EMAIL CONFIRMATION, THE ORDER WAS NOT RECEIVED.

Payment Terms: Net 30 days for E&A clients with pre-approved credit. Otherwise, Credit Card payment will be submitted with this order. A 1.5% monthly finance fee is assessed on all past due client credit accounts. I hereby authorize Jeff Ellis & Associates, Inc. to ship the above order and agree to assume full responsibility for payment for this order according to the terms indicated on this form, including finance charges.

Click this check box to agree to these terms: I AGREE *