Water Safety Instructor Activity Report by ZY8OY2rq


									                                                                                                                                                                                                                                                                                                                                                                                                                                     Water Safety Instructor Activity Report
  CHAPTER INFORMATION                                                                                                                                                                                                               INSTRUCTOR INFORMATION
  [Chapter Contact]                                                                                                                                               Send this                                                                                                                                                           Instructor Name
  American Red Cross of                                                                                                                                           completed
  Western Wisconsin                                                                                                                                               form to the                                                                                                                                                Instructor Address
                                                                                                                                                                  address on the                                                                                                                                                                                                          Street Address
                                                                                                                                                                  left or the e-
  American Red Cross
                                                                                                                                                                  mail address                                                                                                                                                                                                            City, State, ZIP Code
                                                                                                                                                                  or fax number                                                                                                                     Instructor Phone Number
  3728 Spooner Avenue                                                                                                                                             below.
  Altoona, WI 54720                                                                                                                                                                                                                                                          Instructor ID No. or Signature
                                                                                                                                                                                                                                                                            Instructor’s Unit of Authorization
  E-mail Address
                                                                                                                                                                                                                                                                       (If different than Chapter Information)
  Fax Number                                                                                      715-834-4888                                                                                                                      Check here if new address or phone number for instructor

  Provider Name                                                                                                                                                                                                                                                                                                                                                                           Facility Address

  Facility Name                                                                                                                                                                                                                                                                       Facility Phone
                                                                                                                                                                                                                                                                                                                                                                                                               City, State, ZIP Code
  COURSE INFORMATION – Provide the information requested below for each course taught.
  By submitting this form, the instructor acknowledges that the courses were taught according to American Red Cross standards.
                                   Place a check under the course name. Use one row per course                                                                                                                                                                                                                                                                                                                                                                          LMS Schedule
                                                                                                                                                                                Learn-to-Swim                                                                                                                                                                                                                                                                             Instance
                                                                                                                                                                                                                                                            Level 6                                                                                                                                                                                                       Number

                                                                                                                                                                                                                                                                                                                                                     Number Enrolled

                                                                                                                                                                                                                                                                                                                                                                                                                   Completion Date
                                                                                                                                                                                                                                                                                                                                                                          Number Passed
                            Parent and Child Aquatics
Parent and Child Aquatics

                                                                                                                                                                                                                                                                                                                             Personal Water Safety
                                                                                                                                                                                                                                                             Fundamentals of Diving

                                                                                                                                                                                                                                                                                                                                                                                                 Start Date
                                                                                                                                                                                                                                    Personal Water Safety

                                                                                                                                                                                                                                                                                                                                                                                                                                           Name of Co-Instructor or
                                                                                                                                                                                                                                                                                                        Basic Water Rescue
                                                                             Level 2 (HSAQU204)
Level 1 (HSAQU201)

                            Level 2 (HSAQU202)

                                                        Level 1 (HSAQU203)

                                                                                                  Level 3 (HSAQU205)

                                                                                                                       Level 1 (HSAQU206)

                                                                                                                                             Level 2 (HSAQU207)

                                                                                                                                                                     Level 3 (HSAQU208)

                                                                                                                                                                                          Level 4 (HSAQU209)

                                                                                                                                                                                                               Level 5 (HSAQU210)
                                                                                                  Preschool Aquatics
                                                        Preschool Aquatics

                                                                             Preschool Aquatics

                                                                                                                                                                                                                                                                                                                                                                                                                                            Instructor Aide (If Aide,
                                                                                                                                                                                                                                                                                      Fitness Swimmer

                                                                                                                                                                                                                                                                                                                                                                                                                                           place an “A” next to the





     For Red Cross Use Only                                                                                                                 Red Cross Branch                                                                           Chapter                                                    Date                                                                 Date Recorded                          Person Entering/Recording Data                   Auth Provider ID No
                                                                                                                                                                                                                                        Use                                                     Received
                                                                                                                                                                                                                                                                                                                                                                                                                                                                  February 2009

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