BeSeatSmart/NHTSA National CPS Certification Class 2012 Survey

BeSeatSmart/National Child Passenger Safety Training Application Form

Application fee for this training is $75. Make check or money order payable to BeSeatSmart. Do NOT combine fees with another applicant. Checks must be made out for individual fees. (Fee will be refunded if applicant is not accepted) Fee includes registration, training materials and 2-year certification, upon successful completion of the training. Cancellation fee is $30.

Break and Lunch are provided daily, sponsored by BeSeatSmart.

Unlike previous years, there will be no overnight rooms offered for students. We are in process with changing the way that trainings are held and hope to be offering a training in your quadrant of the state within the next two years.

This is a competitive registration. Classes are small. Selected participants will be notified as soon as possible. Please answer the following questions to the best of your ability.

Complete by April 15, 2012 for the May class or September 5, 2012 for the October class

1. Which session do you wish to attend?

Which session do you wish to attend? May

October

*
2. Please fill out your personal contact information. If accepted to the class, your information will be added to our database.

Please fill out your personal contact information. If accepted to the class, your information will be added to our database. Name:
Company:
Address:
Address 2:
City/Town:
State:
ZIP:
Country:
Email Address:
Phone Number:

*
3. Work Contact Information:

Work Contact Information: Work Place:
Job Title:
Address:
City/Town:
ZIP:
State:
Email:
Phone:
Cell Phone:

*
4. Are you a state employee?

Are you a state employee? Yes

No

*
5. Age?

Age?

*
6. Name Tag Preference?

Name Tag Preference?

*
7. Mailing preference?

Mailing preference? Work

Home

*
8. Shirt Gender and Size: Pick One.

	Male	Female
Small	*Shirt Gender and Size: Pick One. Small Male	Small Female
Medium	Medium Male	Medium Female
Large	Large Male	Large Female
X-Large	X-Large Male	X-Large Female
XX-Large	XX-Large Male	XX-Large Female
XXX-Large	XXX-Large Male	XXX-Large Female

*
9. Do you have any dietary restrictions?

Do you have any dietary restrictions? Yes

No

If Yes, please specify:

*
10. Emergency Contact Information:

Emergency Contact Information: Name:
Company:
Address:
City/Town:
State:
ZIP:
Country:
Email Address:
Phone Number:

*
11. What are your typical work hours? Pick one.

	Full Time	Part Time
Days	*What are your typical work hours? Pick one. Days Full Time	Days Part Time
Evenings	Evenings Full Time	Evenings Part Time
Nights	Nights Full Time	Nights Part Time

*
12. What are your current responsibilities and how will you incorporate child passenger safety into your job?

What are your current responsibilities and how will you incorporate child passenger safety into your job?

Applicant and Supervisor

Please review the VT Standards for Child Passenger Safety Technicians. Should you be accepted into the class, you will be sent an agreement that both you and your supervisor will sign and return, indicating agreement of the terms.

In order to maintain certification, all technicians are required to:

Participate in one BeSeatSmart or Safe Kids VT sponsored safety seat inspections each year. These inspections are held throughout the state, April - October. Sign ups happen each spring for returning technicians, new technician sign up will happen during class.

Technicians must complete at least 12 individual safety seat checks annually. This is accomplished by being available for safety seat checks by appointment or participating in a local Vermont Fitting Station.
The checks completed during the large sponsored inspections are included in this total.

Complete Re-Certification through Safe Kids Worldwide by acquiring the required CEU (Continuing Education Units) every two years. $50.00 fee is paid by BeSeatSmart.

For questions, please contact:
Fletcher Allen Health Care
Community Health Improvement
BeSeatSmart Program
Ann Weinstein
199 Main St. Ste 150 until 3/15/12, thereafter, 128 Lakeside Ave. Ste. 106
Burlington, VT 05401
Phone (802) 847-1215
Fax: (802) 847-6545
ann.weinstein@vtmednet.org

BeSeatSmart/NHTSA National CPS Certification Class 2012

1.

1. Which session do you wish to attend?

*2. Please fill out your personal contact information. If accepted to the class, your information will be added to our database.

*3. Work Contact Information:

*4. Are you a state employee?

*5. Age?

*6. Name Tag Preference?

*7. Mailing preference?

*8. Shirt Gender and Size: Pick One.

*9. Do you have any dietary restrictions?

*10. Emergency Contact Information:

*11. What are your typical work hours? Pick one.

*12. What are your current responsibilities and how will you incorporate child passenger safety into your job?