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Name:*

E-Mail Address:*

Why do you want to be a WPA Certified Instructor?*

Professional Water Safety Experience (including but not limited to lifeguard, harbor patrol, instructor). Include Agency, Position and years in position.*

Safety Authority Experience (including but not limited to: fire, police, paramedic, EMT, doctor, nurse and instructor). Include Agency, Position and years in position.*

Current Certifications (i.e. CPR, First Aid, etc.)*

Water Sport Experience more than 1 year (Craft type and years experience)*

Proficient Water Knowledge (Select all that apply):*

Lakes
Ocean

Sporting Achievements*

Instructor/Coaching Experience*

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