subject_line
USA | CAN Instructor Training Registration
Instructor Information
How many instructors would you like to register:
*
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Instructors will still need to complete their registration with the additional link provided in your training confirmation email.
Instructor #1
first name
Instructor #1
last name
Instructor #1
email
Instructor #1
Would you like to add this instructor to your facilities Autoship billing?
*
Yes
No
Instructor #2
first name
Instructor #2
last name
Instructor #2
email
Instructor #2
Would you like to add this instructor to your facilities Autoship billing?
*
Yes
No
Instructor #3
first name
Instructor #3
last name
Instructor #3
email
Instructor #3
Would you like to add this instructor to your facilities Autoship billing?
*
Yes
No
Instructor #4
first name
Instructor #4
last name
Instructor #4
email
Instructor #4
Would you like to add this instructor to your facilities Autoship billing?
*
Yes
No
Instructor #5
first name
Instructor #5
last name
Instructor #5
email
Instructor #5
Would you like to add this instructor to your facilities Autoship billing?
*
Yes
No
Instructor #6
first name
Instructor #6
last name
Instructor #6
email
Instructor #6
Would you like to add this instructor to your facilities Autoship billing?
*
Yes
No
Instructor #7
first name
Instructor #7
last name
Instructor #7
email
Instructor #7
Would you like to add this instructor to your facilities Autoship billing?
*
Yes
No
Instructor #8
first name
Instructor #8
last name
Instructor #8
email
Instructor #8
Would you like to add this instructor to your facilities Autoship billing?
*
Yes
No
Instructor #9
first name
Instructor #9
last name
Instructor #9
email
Instructor #9
Would you like to add this instructor to your facilities Autoship billing?
*
Yes
No
Instructor #10
first name
Instructor #10
last name
Instructor #10
email
Instructor #10
Would you like to add this instructor to your facilities Autoship billing?
*
Yes
No
Instructor #11
first name
Instructor #11
last name
Instructor #11
email
Instructor #11
Would you like to add this instructor to your facilities Autoship billing?
*
Yes
No
Instructor #12
first name
Instructor #12
last name
Instructor #12
email
Instructor #12
Would you like to add this instructor to your facilities Autoship billing?
*
Yes
No
Instructor #13
first name
Instructor #13
last name
Instructor #13
email
Instructor #13
Would you like to add this instructor to your facilities Autoship billing?
*
Yes
No
Instructor #14
first name
Instructor #14
last name
Instructor #14
email
Instructor #14
Would you like to add this instructor to your facilities Autoship billing?
*
Yes
No
Instructor #15
first name
Instructor #15
last name
Instructor #15
email
Instructor #15
Would you like to add this instructor to your facilities Autoship billing?
*
Yes
No
Instructor #16
first name
Instructor #16
last name
Instructor #16
email
Instructor #16
Would you like to add this instructor to your facilities Autoship billing?
*
Yes
No
Instructor #17
first name
Instructor #17
last name
Instructor #17
email
Instructor #17
Would you like to add this instructor to your facilities Autoship billing?
*
Yes
No
Instructor #18
first name
Instructor #18
last name
Instructor #18
email
Instructor #18
Would you like to add this instructor to your facilities Autoship billing?
*
Yes
No
Instructor #19
first name
Instructor #19
last name
Instructor #19
email
Instructor #19
Would you like to add this instructor to your facilities Autoship billing?
*
Yes
No
Instructor #20
first name
Instructor #20
last name
Instructor #20
email
Instructor #20
Would you like to add this instructor to your facilities Autoship billing?
*
Yes
No
Autoship Information
All instructors are required to be on Autoship in order to have "active" status and be eligible to teach that program at their facility. This includes practice teaching in a live class on your schedule, even if the instructor has not passed assessment yet. Non-Certified instructors are elligible to order releases and receive Autoship releases up to 90 days after their inital training.
Please select one of the options below in regards to how your facility manages instructors Autoship releases.
*
Our facility pays for some or all of our instructors Autoship releases.
Instructors at our facility are required to pay for their own Autoship releases.
Autoship Billing Information
Please verify your credit card information below to be billed on your credit card for quarterly Autoship.
Name on Card
*
Facility Name Associated with Card
*
Credit Card Type
*
Visa
MasterCard
American Express
Discover
Credit Card Number
*
Expiration Date (mm/yy)
*
CSV code
*
Billing Street Address for Credit Card
*
Billing City for CC
*
Billing State for CC
*
Billing Zip Code for CC
*
Additional Comments
Training Event Information
To access the event number, date, and location for the training you would like to request, please
click here
to see the Training Calendar.
(Right click the link and open in a new tab.)
event number of training requested
*
date of training requested
*
city of training requested
*
province/state for training requested
*
Contact Information
Please fill in the following information of the person filling out this form.
By filling in the information below you accept that you are authorized by the facility to make legal decisions on their behalf.
first name
*
last name
*
facility name
*
position
*
address line1
*
address line2
city
*
state
*
zip code
*
email
*
phone number
*
Additional Comments