Registration Form
Please, print this page and complete it.
Name_________________________________________________________________
Age___________________________________________________________________
Address_______________________________________________________________
City/State/Zip: __________________________________________________________
Phone (day):____________________________________________________________
Phone (evenings) ________________________________________________________
E-Mail: ________________________________________________________________
I would like to register for the 75 Hour - 2002 National Outdoor Top Rope
Instructor Certification Course.
Included is my deposit of $325, the remaining balance of $325 should be received
from you at least 14 days of your arrival for your scheduled course session:
First Choice: Dates: _____________
Second Choice: Dates: _____________
I would like to register for the 75 Hour - 2003 National Top Rope Instructor
Certification Course.
Included is my refundable deposit of $325. The remaining balance of $325 should
be received by us approximately 14 days prior to your arrival for your scheduled
course session:
I would like to pre-register for the 2003 National Outdoor Top Rope Instructor
Re-Certification Weekend Review Course. April 5 & 6; April 12 & 13; April 19 &
20; May 10 & 11; June 14 & 15.
Included is my refundable deposit of $100. The remaining balance of $175 should
be received by us 14 days prior to your arrival for your scheduled weekend
course:
First Choice: Dates: _____________
Second Choice: Dates: _____________
Please rate your current top rope climbing background and abilities:
Just beginning / one to five years / six years and longer
List the reasons why you would benefit from this National Outdoor Top Rope
Instructor Certification Course?
Where did you hear about this National Outdoor Top Rope Instructor Certification
Course?
By this registration I acknowledge that I am participating in this course at my
own risk at all times and in all conditions. I have read the brochure and the
conditions applying to the operation of the National Top Rope Instructor
Certification Course and I understand and accept these conditions.
I understand that the National Outdoor Top Rope Instructor Certification Course
does not provide accident/illness insurance; therefore, any medical bills and
any prescriptions I may need as a result of activities in which I will
participate through Kirkwood Community College and through the National Outdoor
Top rope Instructor Certification Course are my responsibility. I give my
permission for any photographs taken of me to be used to promote the National
Outdoor Top Rope Instructor Certification Course.
Signed:___________________________________________________
Date:_____________________________________________________
Make checks or money orders out to Kirkwood Community College Memo: National
Outdoor Top Rope Instructor Certification Course.
Please Mail to:
Larry Lutz, MPA, CPRP
Kirkwood Community College
Recreation/Leisure Services
6301 Kirkwood Blvd.S.W.
P.O. Box 2068
Cedar Rapids, Iowa 52406
Toll Free: 1-800-332-2055, Ext. 4912
Phone: 319-398-4912
Fax: 319-398-5432
E-mail: lLutz@kirkwood.cc.ia.us
www.kirkwoodcollege.com
Instructor E-Mail: TopRopeCertification@yahoo.com Communicate directly with Jim
Ebert, the Director of the National Top Rope Instructor Training Course.
E-mail Jim for additional National Top Rope Instructor Certification Course
Information Pamphlets or if you have any questions.
National Outdoor Top Rope Instructor Certification Course Web Site: [Larry, This
Site will be finished by
this next weekend except for the additional Kirkwood Registration Information]
http://www.topropecertification.com