Instructor Qualification Clinic Application - American Sailing Association

I. PERSONAL INFORMATION

Name*

First Middle Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email*

Phone*

ASA ID Number #: (if available)

Have you ever been convicted of a felony? Check One:*

Yes
No

If yes, please explain:

II. SAILING EXPERIENCE

(101 Basic Keelboat required for instructor certification)

1. How and where did you learn to sail? Include contact names and numbers if possible.

2. What types of small boats, keelboats and multihulls have you crewed on, # years, and where?

3. What types of small boats, keelboats, and multihulls have you skippered, # years, and where?

4. What types of small boats, keelboats, and multihulls have you chartered/rented, # years, and where?

5. Explain your navigational qualifications, racing experience, racing direction, and markset experience, if any:

6. Have you ever been responsible for a boating accident where another person sustained bodily injury?:

Yes
No

If yes, please explain:

7. Where and what is your teaching experience?

III. PAST EXPERIENCE

Upload Certifications/Documents:

Drop files here or

IV. INSTRUCTOR CERTIFICATION REQUIREMENTS

Course	Price
ASA INSTRUCTOR PREPARATION (200)	$99.00
BASIC KEELBOAT SAILING INSTRUCTOR (201)	$99.00
BASIC COASTAL CRUISING INSTRUCTOR (203)	$99.00
BAREBOAT CRUISING INSTRUCTOR (204)	$99.00
COASTAL NAVIGATION INSTRUCTOR (205)	$99.00
ADVANCED COASTAL CRUISING INSTRUCTOR (206)	$99.00
CELESTIAL NAVIGATION INSTRUCTOR (207)	$99.00
OFFSHORE PASSAGEMAKING INSTRUCTOR (208)	$99.00
BASIC SMALL BOAT SAILING INSTRUCTOR (210)	$99.00
CRUISING CATAMARAN INSTRUCTOR (214)	$99.00

V. PAYMENT

Total

$0.00

Credit Card*

American Express

Discover

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name

VI. SIGNATURE

I understand fully that by signing this agreement I have studied, and prepared for the intense requirements to become an Certified ASA Instructor. I agree to the Terms and Conditions and the ASA Code of Ethics to the best of my ability.

I understand that once I am an ASA Certified Instructor I will need to certify students through an ASA Affiliate School.

Name:*

Date:*