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* 1. First Name

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* 2. Last Name

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* 3. Professional Title

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* 4. Employer

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* 5. Address

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* 6. Please provide your emergency contact information.

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* 8. Are you affiliated with a Montana Department of Public Health and Human Services Program (DPHHS)? If yes, please select which one (choose all that apply)

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* 9. Select all that apply

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* 10. Please Indicate your current training certification(s) and type(s) Ex: Certified Yoga Instructor, Bachelors or higher in exercise science, Certified Athletic Trainer, etc.

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* 11. Do you currently work with any individuals with disabilities? 

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* 12. Please list any allergies or medical dietary needs we should be aware of.

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* 13. What new information do you hope to gain from this workshop?

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* 14. • Would you be interested in taking the ACSM CIFT Exam on Thursday, May 16th or Friday, May 17th on the UM campus?

**Note: A current ACSM or NCAA-accredited health/fitness-related certification OR Bachelors Degree in Exercise Science, Recreation Therapy or Adapted Physical Education and an Adults CPR/AED certification is required to register for the exam. (A separate registration form will be sent to you if you indicate interest).

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* 15. If you are interested in scheduling the CIFT exam for a later date, please indicate your preference.

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* 16. The Montana Disability and Health Program (MTDH) can support CIFT exam fees for a limited number of qualified individuals who will serve as 'Inclusive Fitness Champions' (IFC) in Montana communities. Please indicate your interest in learning more about or becoming Inclusive Fitness Champions and MTDH staff will send you more information.

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