Training Center Application Form (Fields marked with * are required)

1) Site*:
     Starfish (Aquatics Institute):     Emergency Care (HK-ASHI):
2) What programs do you plan to offer through your Training Center *? (Check all that apply)
ProgramWhen do you plan Start-up?
StarGuard (includes Complete Emergency Care) Immediately Within 6-12 months Within 12-18 months Will not teach this program
Starfish Swim School Immediately Within 6-12 months Within 12-18 months Will not teach this program
AquaTech (pool operator course) Immediately Within 6-12 months Within 12-18 months Will not teach this program
Safety Training & Aquatic Rescue (STAR basic water safety course) Immediately Within 6-12 months Within 12-18 months Will not teach this program
Complete Emergency Care (CPR/AED, First Aid, Bloodborne Pathogens and Emergency Oxygen in one course) Immediately Within 6-12 months Within 12-18 months Will not teach this program
CPR/AED Immediately Within 6-12 months Within 12-18 months Will not teach this program
Basic First Aid Immediately Within 6-12 months Within 12-18 months Will not teach this program
3) Please check Box (es) that indicate Your Business Structure and any affiliation *:
Sole Proprietorship
Corporation, Limited Liability Corporation, Partnership
Professional Association
Municipality/Parks & Recreation
Non-Profit Organization
Military
Public Safety Agency
Educational Institution
Other
Are you an existing Human Kinetics Emergency Care Training Center? Yes  No
Are you an existing ASHI Training Center? Yes  No
 
4) Training Center Director *: The Director is the business owner, an executive officer, or other responsible individual associated with the organization who is authorized to obligate themselves and their organization to the terms of the Training Center agreement that will be signed upon meeting all training requirements. (The Director can be the same as the Point of Contact requested below or another designated individual)
First Name*:   Last Name*:
         Email*:
Address1*:
Address2:
            City*:    Province/State*:    Zip*:
Country*:    
      Phone*:    Fax:
 
5) Training Center Point of Contact *: The Point of Contact is the individual who will implement the Starfish Aquatics Institute training initiatives and manage administrative responsibilities. (The POC can be the same as the Training Center Director or another designated individual.)
First Name*:   Last Name*:
         Email*:
Facility/Organization Name:
Training Center Name *:
Address1*:
    Address2:
            City*:    Province/State*:     Zip*:
Country*:    
          Phone:     Fax:
 
6) Training season: Year-round  Seasonal
    If Seasonal, Start Month (ex. 05 for May):
    End Month (ex. 05 for May):
7) Number of training locations *:
    How many are within a 30 minute drive of each other?
8) Types of training locations (check all that apply and indicate the number of each) *:
Indoor Pool  #
Outdoor Pool  #
Waterpark
Gymnasium
Sports Facilities
Retirement
Comm/Senior Center
Fitness Center
Community Center
Other  #
9) Director or Point of Contact Qualifications (Check all that apply):
MD/DO
PhD/EdD
NP/MA/MS/MEd
BA/BS/BSN
RN
PA
RT
LPN
AA/AS/AAS
NREMT-P/EMT-P
NREMT-B/EMT-B
CNA
Wilderness First Aid
Wilderness First Responder
State Certified Teacher
Wilderness Education Instructor
EMS Instructor
Firefighter
Fire Officer
Fire Service Instructor
Law Enforcement Officer
Law Enforcement Instructor
AFO [or CPO] Instructor
ARC Instructor or Instructor Trainer
NSC Instructor or Instructor Trainer
Starfish Aquatics Instructor or Instructor Trainer
YMCA Instructor or Instructor Trainer
Ellis & Associates Instructor or Instructor Trainer
AHA Instructor or Instructor Trainer
Other
10) Indicate the number of individuals you or your organization trained last year in the following topics through another nationally recognized organization. Enter 0 if none.*
Lifeguards
Lifeguard Instructors
Swimming instructors
Swim lessons
CPR
Other
Organization:
Starfish Aquatics
ARC
Ellis & Assoc.
YMCA
NASCO
Other
11) How did you hear about the Starfish Aquatics Institute and the HK Aquatic Education Center?
Colleague/Friend
Internet Search
Tradeshow
ASHI Representative
HK Representative
Trade Journal/ Publication
Other
12) Type of insurance *:
Government or State Sovereign Immunity applies
Self-insured group:
      Contact Name: Phone:
General and Professional Insurance through a rated carrier:
     Insurance Company:
     Broker, Agent or Contact Name:
     Phone:
13) Professional References:
Contact Name: Phone:
                Email:
Contact Name: Phone:
                Email:
Contact Name: Phone:
                Email:
14) Who is your Intended Audience(s)? (Check all that apply):
Lifeguards working at/for the Training Center sites(s)
General Public
Day Care Providers
In-Hospital Health Care Professionals
Out-Of-Hospital EMS Professionals
Public Safety Professionals
Community and Workplace Lay Rescuers
Wilderness Trip Leaders and Guides
Military Personnel
Resort/Club Personnel
Foster Parents
Swim Coaches
Personal Trainers
Athletic Trainers
Aquatic Management Personnel
Other
Scholastic Coaches (Grades 5-12)
Youth Sport Coaches (Up to Age 14)
Competitive Club Sport Coaches
College/University Sport Coaches
General Public
Other
15) Training Center Agreement *:
Effective on the date of application, I understand and agree for myself and all other persons acting on my behalf or on behalf of my HK Training Center;
a) That approval and authorization as a Starfish Aquatics Institute-HK Training Center is a privilege, not a right and may be revoked.
b) To teach all Starfish Aquatics Institute- HK programs and operate in accordance with the most recent version of the Training Center Administrative Manual that will be provided as part of the training center and instructor development process.
If you agree with these statements, click here.

Please complete all questions before submitting your application, as you will be unable to return to the form later. We will contact you during the application review process if further information is needed.