AMPED2PLAY Course Registration Profile

Please complete the following registration profile prior to initiating your AMPED2PLAY Training. Thank you!

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* 2. Course Location:

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* 3. Date of Course:

Date (MM/DD/YYYY)

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* 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.

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* 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.

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* 7. Your Contact Information:

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* 8. Please Provide a Birthdate:

Birthdates are for internal tracking purposes only

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* 9. Please Provide Your Gender:

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* 10. Emergency Contact:

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* 11. What Drew You to This AMPED2PLAY Program?

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* 12. Your Area of Specialty (Select all that apply):

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* 13. Your Role (Select all that apply):

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* 14. Your Organization:

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* 15. Your Area of Interest (Select all that apply):

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* 16. Please Select the Type of Programming/Development Opportunities That Interest You:

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* 17. Do you currently participate in any community, recreation, or professional programming? If so, which programs?

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* 18. What Program Do You Currently Participate In?

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* 19. What Current Certification(s) Do You Hold?

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* 20. What is Your Preferred Language?

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* 21. Photo Release:

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