Instructor Trainer - Lifesaving Society

1Instructor TrainerSide 1: Please print each candidate's name and contact information legibly.Sex MFDate of BirthY/M/DPrerequisites CheckedLifesaving Society1TeachingCommunicationClass ManagementPlanningEvaluation2 3 4 5 6ResultNameAddressCityPostal codeE-mail2NameTelephoneSex M FAddressCityPostal codeE-mail3NameTelephoneSex M FAddressCityPostal codeE-mail4NameTelephoneSex M FAddressCityPostal codeE-mail5NameTelephoneSex M FAddressCityPostal codeE-mail6NameTelephoneSex M FAddressCityPostal codeE-mailBranch Trainer's NameCheck box if there are more candidates on the reverse side of this page.This test sheet is page ___ of ___ pages.Branch Trainer InformationTelephoneID# Satisfactory PerformanceClinic InformationStart Date:F FailTotal Pass forClinicEnd Date:Total Fail for ClinicYY MM DD YY MM DDE-mail( )Telephone SignatureBranch Trainer's NameE-mail( )Telephone SignaturAwards informationAwards issued by affiliateAwards not issuedID#Facility namePayment informationExam fees attachedExam fees not attachedSend invoice or receipt toAffiliateAddressReturn completed test sheet to the Lifesaving Society Branch Office promptly after the exam. Retain one copy for your records. Do not sent cash by mail.( )Telephone( )TelephoneCity Province Postal code

Instructor TrainerSide 2: Please print each candidate's name and contact information legibly.Date of BirthPrerequisites CheckedLifesaving SocietyTeachingCommunicationClass ManagementY/M/D 1 2 3 4Planning5Evaluation6Result7Sex MFNameAddressCityPostal codeE-mail8NameTelephoneSex M FAddressCityPostal codeE-mail9NameTelephoneSex M FAddressCityPostal codeE-mail10NameTelephoneSex M FAddressCityPostal codeE-mail11NameTelephoneSex M FAddressCityPostal codeE-mail12NameTelephoneSex M FAddressCityPostal codeE-mailTelephoneCheck box if there are more candidates on the reverse side of this page.This test sheet is page ___ of ___ pages.Clinic Information Satisfactory PerformanceBranch Trainer InformationF FailTotal Pass forClinicTotal Fail for ClinicStart Date:End Date:YY MM DDYY MM DDBranch Trainer's NameID#( )name TelephoneE-mail( )TelephoneSignaturePlease complete BranchTrainer, Awards and Payment information sections on Side 1 of test sheet. Hostname, Clinic information, and Branch Trainer sections must be completed on both sides 1 and 2 of thetest sheet.Branch Trainer's NameE-mailID#( )TelephoneSignatureReturn completed test sheet to the Lifesaving Society Branch Office promptly after the exam. Retain one copy for your records. Do not sent cash by mail.