NATIONAL SKI PATROL
EDUCATION PROGRAM
CERTIFIED CANDIDATE/RECERTIFICATION APPLICATION
|
|
NATIONAL SKI PATROL |
| PERSONAL DATA | |
|---|---|
| Name | Date |
| Address | NSP ID # |
| City, State, Zip | SS # |
| Daytime Phone | Evening/Wknd Phone |
| Please check as appropriate | |||||
| New Application |  Yes |
No |
Reapplication | Yes |
No |
| Recertification | Yes |
No |
Reactivation | Yes |
No |
If for Recertification or Reactivation, please provide your Certified Number__________________________
Patrol history (List most recent first)
Total Years of Experience__________________ Average Number of Days per Year__________________
| Patrol Name |
Location |
|
| From: | To: |
Full Time Paid
Volunteer |
| Patrol Name |
Location |
|
| From: | To: |
Full Time Paid
Volunteer |
| Patrol Name |
Location |
|
| From: | To: |
Full Time Paid
Volunteer |
Please check as appropriate
| Senior |
Senior Ski and Toboggan
Evaluator |
| Senior Emergency
Management (Sr. OEC) |
Senior OEC Evaluator |
| OEC Instructor |
|
| OEC Instructor Trainer |
|
| Instructor
Development (Phase I) |
Instructor
Development (Phase I) Instructor |
| Global Module: Phase II |
Instructor
Development (Phase I) Instructor Trainer |
| Advanced
Instructional Skills Module: Phase II (discipline ______________) |
|
| Alpine Toboggan Instructor |
Alpine Toboggan Instructor
Trainer |
| Avalanche Fundamentals
& Rescue |
Level I Avalanche
Instructor |
| Level I Avalanche
(Basic Avalanche) |
Level II Avalanche
Instructor |
| Level II Avalanche
(Advanced Avalanche) |
Avalanche
Instructor Trainer |
| Mountain
Travel & Rescue Fundamentals |
Level I Mtn.
Travel & Rescue Instructor |
| Level I Mtn.
Travel & Rescue (Basic Mountaineering) |
Level II Mtn.
Travel & Rescue Instructor |
| Level II MTR
(Advanced Mountaineering) |
Mountain Travel
& Rescue Instructor Trainer |
| EMT |
EMT Instructor |
| Other __________________________________________________________________________ |
|