1 2009 Northwest YMCA Regional Training Event - Registration Form by brokeNCYDE


									                                                                  Register online at:
  2009 Northwest YMCA Regional Training Event - Registration Form
  Complete the information requested on each line. Please print.  regionaltrainingeventportland

  Name: _________________________________________________________________ Gender:                   M     F

  Birthdate: _______________________________________ Last 4 Digits of SSN: _____________________

  YMCA job title: ____________________________________ E-mail: _______________________________________

  I will arrive at the event by: car plane NOTE: If arriving by plane, contact the director to check on course
  cancellations before making non-refundable travel arrangements.
  YMCA Association & Branch Name: ___________________________________________________________________

  YMCA Address: _____________________________________ City: ______________ State: _____ Zip: _________

  YMCA Supervisor’s Name/Title: ______________________________________________________________________

  Emergency Contact: (name)_____________________________Day Phone_____________Evening_________________

  Circle the corresponding course fee(s) for each course for which you are registering. Check the chart to make sure
  your course times do not overlap. Refer to course descriptions for prerequisites.

                                                 Wed, 11/11    Thur, 11/12    Fri, 11/13     Sat, 11/14    Sun, 11/15
                                          Fee      Time          Time           Time           Time          Time
Membership & General Training
Training Others I                         $30     2-5pm
Training Others I Trainer                 $60     12-6pm
Creating the Member Experience            $70                   9am-4pm
The Keys to Member Engagement             $70                                  9am-4pm
Grant Writing                             $40                                                              8am-noon
Introduction to Time Management           $40                                                               1-5pm
Networking Fun & Fellowship                                      5-9pm
YMCA Swim Lesson Instructor               $130                  8am-5pm        8am-5pm       8am-5pm
YMCA Swim Lesson Instructor Trainer       $150    8am-6pm       8am-6pm        8am-6pm       8am-6pm          8am-6pm
Youth & Teen
Principles of Youth Work 12-17 yr olds    $70     8am-5pm
Y Teen Leadership: A Club Approach        $100                                 8am-5pm
Working with Low Income Kids              $40                                                8am-noon
Working with Program Volunteers           $40                                                 1-5pm
Understanding Teen & Substance Abuse      $70                                                                 8am-5pm
Child Care & Day Camp
Infant–Toddler/Preschool Child Care Dir   $110                                 8am-5pm       8am-5pm
Infant–Toddler/Preschool CC Dir Trainer   $130     6-9pm        8am-5pm        8am-5pm       8am-7pm
Administering YMCA Early Childhood and    $110                                               8am-5pm          8am-5pm
Afterschool Programs
Health & Wellness
Healthy Lifestyle Principles              $40      4-8pm
Foundations of Group Exercise             $70                   8am-5pm
Foundations of Group Exercise Trainer     $90      6-9pm        8am-7pm
Sports Conditioning                       $40                                 8am-noon
Flexibility Training                      $40                                  1-5pm
                                                    Wed, 11/11    Thur, 11/12      Fri, 11/13     Sat, 11/14     Sun, 11/15
Leadership Competency Modules
Volunteerism                               $190        1-5pm        8am-5pm
Volunteerism Trainer – Renee Brouse        $210       9am-5pm       8am-7pm
YMCA Program Management                    $200                                                   8am-5pm         8am-5pm
YMCA Program Management Trainer            $220                                     6-9pm         8am-5pm         8am-7pm
Annual Community Support Campaign          $250                                    8am-5pm        8am-5pm         8am-5pm

  Compute the total course fee(s)
                                                  Total Fee: _____________

                           □ Check made payable to YMCA of Tacoma-Pierce County
  Payment options (Mark one):

                           □ Credit card □ Visa □ MC □ AMEX □ Discover
  Credit card account #: ____________________ __/__

  ___________________________________                  ___________       _________________________
  Cardholder signature (required)                      Date              Cardholder’s daytime phone #

  Cardholder’s name (please print clearly)

  Supervisor checklist: Prerequisites and textbooks

      •   I have read the course prerequisites and confirm that all will have been met for the courses indicated on this form
          either before or during the Regional Training Event.
      •   I have checked the course description for required textbooks and have ordered them if necessary.
      •   I have shared a copy of the brochure with the person registering for this event.

  Executive Director or YMCA supervisor’s signature (required for participation)

  Mail the following items no later than October 26, 2009 to: Alyssa Blackburn
                                                           YMCA of Tacoma-Pierce County
                                                           1614 S. Mildred St, Ste 1
                                                           Tacoma, WA 98465

      •   This registration form
      •   Trainer Candidate Application (if applying for a trainer-level class)-no later than October 9, 2009
      •   Payment that includes the course fee for each course and late fee, if applicable.

  For questions concerning your registration and all other questions, contact Alyssa Blackburn at (252) 534-7806 or


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