INSTRUCTOR TRAINING REGISTRATION Please complete all required fields to successfully submit your registration. Question Title * 1. Contact Information Name * Address * Address 2 City/Town * State/Province * ZIP/Postal Code * Country * Email Address * Phone Number * Question Title * 2. Birthday Month Day Year Birthday January February March April May June July August September October November December Birthday Month menu 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Birthday Day menu 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 Birthday Year menu Question Title * 3. Gender Female Male Prefer not to disclose Other (please specify) Question Title * 4. Education High School College Post Graduate Degree Question Title * 5. Teaching and Presentation Skills I currently present and demonstrate materials about fitness and health on an ongoing basis I currently present materials about fitness and health to groups on an ongoing basis I have presented to groups and individuals in the past I have never presented materials bout fitness and health I regularly do public speaking, teaching, and presentations I have done little public speaking, teaching, or presenting Question Title * 6. Chirunning & Chiwalking Experience Read ChiRunning Book Read ChiWalking Book Read ChiMarathon Book Viewed ChiRunning DVD Viewed ChiWalking DVD Viewed Hills and Trails DVD Viewed ChiWalk-Run DVD Listened to ChiRunning CD One-on-one Instruction in ChiRunning One-on-one Instruction in ChiWalking Participated in 1-Day Workshop Participated in Half-Day Workshop None of the above Question Title * 7. Length of time practicing ChiRunning/ChiWalking less than 1 year 1-2 years 3-5 years more than 5 years Question Title * 8. To what extent do you feel you have learned the techniques? Totally transformed my running / walking To a great extent To some extent To a small degree Not at all Question Title * 9. What terrain do you run/walk on? Road Dirt Road Track Trail Hill Treadmill Other (please specify) Question Title * 10. Participation in the following events. Yes/No Number of Times 5K Yes No 5K Yes/No menu 1 2 3 4 5 6 7 8 9 10+ 5K Number of Times menu 10K Yes No 10K Yes/No menu 1 2 3 4 5 6 7 8 9 10+ 10K Number of Times menu Half Marathon Yes No Half Marathon Yes/No menu 1 2 3 4 5 6 7 8 9 10+ Half Marathon Number of Times menu Marathon Yes No Marathon Yes/No menu 1 2 3 4 5 6 7 8 9 10+ Marathon Number of Times menu Ultra Marathon Yes No Ultra Marathon Yes/No menu 1 2 3 4 5 6 7 8 9 10+ Ultra Marathon Number of Times menu Triathlon Yes No Triathlon Yes/No menu 1 2 3 4 5 6 7 8 9 10+ Triathlon Number of Times menu Other (please specify) Question Title * 11. Academic Sports and Fitness Training or Study Yes No Question Title * 12. Please Describe (If "Yes" to Question 11) Question Title * 13. Other sports in which you participate. Running Walking Swimming Bicycling Other (please specify) Question Title * 14. Other Physical Fitness Certifications/ Qualifications AFAA NASCM ACE Yoga Instructor Spinning Instructor Pilates Instructor T'ai Chi Instructor Group Trainer Personal Trainer Other Martial Arts Instructor Personal Trainer Insurance Red Cross CPR Certification (required for Certification) Other (please specify) Question Title * 15. Do you have a regular fitness program? yes no Question Title * 16. Number of Years (If "Yes" to Question 15) Less than 1 1 2 3 4 5 6 7 8 9 10+ Question Title * 17. Number of Days per Week (If "Yes" to Question 15) 0 1 2 3 4 5 6 7 Question Title * 18. Distance per Week (If "Yes" to Question 15) Question Title * 19. Average Training Pace (If "Yes" to Question 15) Below 8 minutes 8-10 minutes 10-12 minutes 12+ minutes Question Title * 20. Number of Walking or Running injuries in past 2 years 0 1 2 3 4 5+ Question Title * 21. Type of Injury Over-use Impact Lower Back Hips/IT Band Knees Lower Legs/Feet Surgical Other (please specify) Question Title * 22. Choose Course Title OR Instructor Name Write in your course city and year Write in your instructor's name Question Title * 23. Goals of the Training Workshop (Please write 250-500 words that describes why you want to become a ChiRunning & ChiWalking Instructor) Question Title * 24. Any other information that has not been covered but that you would like us to know. Done
