Walk with Ease Program Registration

* required information
Registration 
PERSONAL INFORMATION
First Name:*
Middle Initial:
Last Name:*
Email:*
Address Line 1:*
Address Line 2:
City:*
State:*
ZIP/Postal Code:*
Phone:
Job Title:
Company Name:
Work Address:
Work City:
Work State:
Work Zip Code:
Arthritis Foundation Region/Chapter Affiiliation:*
For Arthritis Foundation correspondence, please contact me at: My worksite (if applicable)
My home
FEES
$50.00 Standard Registration
General Registration
DISCOUNT
If you have received a discount code, please enter it here:
DONATION (optional)
If you would like to take this opportunity to support the Arthritis Foundation, please enter the amount below.
Amount:$
ADDITIONAL INFORMATION (PLEASE PROVIDE INFORMATION ABOUT THE HOST FACILITY WHERE YOU PLAN TO CONDUCT THE ARTHRITIS FOUNDATION WALK WITH EASE PROGRAM IF DIFFERENT FROM YOUR WORK LOCATION LISTED ABOVE)
FACILITY NAME:
Facility Address:
Facility City:
Facitlity State:
Facility Zip Code:
Administrator/Contact Person Name:
Administrator/Contact phone number:
Administrator/Contact email address:
Does the facility have a signed Program Co-Sponsorship Agreement with the AF?:* Yes
No
Do you have a current adult CPR certification?:* Yes
No
Do you have current First Aid certification? (Recommended):* Yes
No
List all other relevant certifications and their expiration dates:
What professional or volunteer experience have you had leading education or exercise classes, workshops, or public speaking?:
What is your background in health, fitness, or education? List any relevant degrees or course work:
What other experience do you have that would be beneficial in leading the Walk With Ease Program?:
What is your experience with arthritis (personal or family member, or work with people who have arthritis)?:
Please tell us why you want to teach the Arthritis Foundation Walk With Ease Program:
How did you hear about this program?:
Have you been a participant or leader/instructor in any other Arthritis Foundation programs and if so, please list:

By submitting this registration, I acknowledge that I have read and understand the statements and requirements for my training and continued participation as an Arthritis Foundation Walk With Ease Leader as outlined in the Statement of Understanding. Please print a copy of this form, sign and return it to your local Arthritis Foundation Office.