Arthritis Foundation Program Leader Validation Form

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* 1. Please select the Arthritis Foundation Program(s), you teach:

Aquatic Program (AFAP)

Exercise Program (AFEP)

Aquatic and Exercise Programs (AFAP/AFEP)

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* 2. Program Leader Name

First Name

Last Name

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* 3. Contact Information

Company Name

Address line 1 *

Address line 2

City/Town *

State/Province *

ZIP/Postal Code *

Email Address *

Day Phone Number *

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* 4. Arthritis Foundation Certificate Number
(if you do not have indicate so)

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* 5. Arthritis Foundation Certificate Expiration

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* 6. CPR/AED Expiration Date

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* 7. CPR/AED Issued By

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* 8. How many Exercise Program classes do you teach per week?
*if you do not teach AFEP, please enter 0 below.

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* 9. How many Aquatic Program classes do you teach per week?
*if you do not teach AFAP, please enter 0 below.

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* 10. Please list all sites/locations (site name, city, state) you teach classes at:

*I attest the information provided in this form is true and must follow the mandated program protocol as designated in Program Manual. I do understand that if any information provided above is fraudulent my Program Leader status will be revoked immediately and any certificate I hold will be deemed null and void.

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* 1. Please select the Arthritis Foundation Program(s), you teach:

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* 2. Program Leader Name

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* 3. Contact Information

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* 4. Arthritis Foundation Certificate Number(if you do not have indicate so)

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* 5. Arthritis Foundation Certificate Expiration

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* 6. CPR/AED Expiration Date

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* 7. CPR/AED Issued By

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* 8. How many Exercise Program classes do you teach per week?*if you do not teach AFEP, please enter 0 below.

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* 9. How many Aquatic Program classes do you teach per week?*if you do not teach AFAP, please enter 0 below.

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* 10. Please list all sites/locations (site name, city, state) you teach classes at:

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* 11. Program Leader Acknowledgment

* 4. Arthritis Foundation Certificate Number
(if you do not have indicate so)

* 8. How many Exercise Program classes do you teach per week?
*if you do not teach AFEP, please enter 0 below.

* 9. How many Aquatic Program classes do you teach per week?
*if you do not teach AFAP, please enter 0 below.