AMPED2PLAY Professional Certification AMPED2PLAY Course Registration Profile Please complete the following registration profile prior to initiating your AMPED2PLAY Training. Thank you! OK Question Title * 1. Name of Course: PLAY6S Foundation Certificate - 6 hour course PLAY6S Practical Training - 6 hour course PLAY6S Certification Completion - 16 hours Ramshackle Play Foundation Certificate - 6 hour course Ramshackle Play Practical Training - 6 hours Ramshackle Play Certification Completion - 16 hours Play Professional Mentor Program Play Professional Evaluator Play Medium Workshop - 2 hours Play Skills for Children Workshop - 2 hours Play Skills for Seniors Workshop - 2 hours Play Skills for Families - 2 hours Arts Play - 2 hours Growth Mindset / Braving Play - 7 hours OK Question Title * 2. Course Location: City Province/State Country OK Question Title * 3. Date of Course: Date (MM/DD/YYYY) Date OK Question Title * 4. My Role in This Course Is as a: Course Facilitator Course Participant - In the Certification Pathway Course Participant - 6 hour Certificate Only Volunteer OK Question Title * 5. Any and all AMPED2PLAY courses and trainings cannot be recorded via video or audio unless explicit written consent is given to the requesting party by the AMPED2PLAY Training officer. I understand OK Question Title * 6. Personal Information: The information provided in this section is only for use of tracking individuals for AMPED2PLAY training and certification programs and related liability purposes and will in no way be distributed for any other purpose. If you are in agreement to provide your information, please check the box below. I agree to provide my personal information for AMPED2PLAY training and certification tracking OK Question Title * 7. Your Contact Information: Name * Address Address 2 City/Town * State/Province * ZIP/Postal Code * Country * Email Address * Phone Number OK Question Title * 8. Please Provide a Birthdate: Birthdates are for internal tracking purposes only Date OK Question Title * 9. Please Provide Your Gender: Female Male Non-Binary Two-Spirit Prefer Not To Say Other (please specify) OK Question Title * 10. Emergency Contact: Name Relation Primary Phone Secondary Phone OK Question Title * 11. What Drew You to This AMPED2PLAY Program? General interest Relates to my area of speciality I am interested in providing delivery in this area of knowledge I am interested in this area of speciality being made available in my organization I am interested in becoming fully certified in this area of speciality I am interested in acquiring the rights to act as an AMPED2PLAY delivery organization Other (please specify) OK Question Title * 12. Your Area of Specialty (Select all that apply): Educator Recreation Provider Community Support Provider Health Care Provider Sport Business (For Profit) Business (Not for Profit / Social Enterprise) Management Subject Matter Expert Other (please specify) OK Question Title * 13. Your Role (Select all that apply): Practitioner Instructional Teacher Instructional Support Coach Executive Management Administration Leader/Builder Paid Staff - Full Time Paid Staff - Part Time Student Volunteer Other (please specify) OK Question Title * 14. Your Organization: Not for Profit Government Education (K to 12 or related) Education (Post Secondary - University, College, etc.) Health Provider (Government) Health Provider (Private - For Profit) Corporate/Business (For Profit) Not Presently Employed Other (please specify) OK Question Title * 15. Your Area of Interest (Select all that apply): Sport/Performance Play/Recreation Adaptation/Inclusion Children Focus Seniors Focus Multigenerational Interest Corporate/Professional Business Productivity Improvement Other (please specify) OK Question Title * 16. Please Select the Type of Programming/Development Opportunities That Interest You: Training Volunteer Opportunities Community Programming Opportunities Recreation Opportunities Sport Specific Opportunities Certification Workshops Corporate Retreats Team Building Opportunities Leadership Opportunities Business Development Business (Regional Delivery Partner) Other (please specify) OK Question Title * 17. Do you currently participate in any community, recreation, or professional programming? If so, which programs? Professional Sport Focused Recreation Focused Programming Community Focused Programming Other (please specify) OK Question Title * 18. What Program Do You Currently Participate In? OK Question Title * 19. What Current Certification(s) Do You Hold? NCCP FMS NCCP Community Coach NCCP Instructor NCCP Competition Coach - Entry Level NCCP Competition Coach - Development Level NCCP Competition Coach - Performance Level High5 DancePlay Special Olympics None Other (please specify) OK Question Title * 20. What is Your Preferred Language? English French Other (please specify) OK Question Title * 21. Photo Release: I, as a participant in this AMPED2PLAY course, give full permission to use any photographs or movies taken during the course. I, as a participant in this AMPED2PLAY course, do NOT give permission to use any photographs or movies taken during the course. OK DONE