ChiWalking Instructor Application

Steps to Register

STEP 1
Read the Instructor Program Information
STEP 2
Fill out the course application
STEP 3
Read, sign and mail the Instructor agreement
STEP 4
Buy the home study program
STEP 5
Sign up for the Course

Personal Information
Course Location
Course Date
 
 
State
Zip Code
Home Phone
Date of Birth
 
Please use MM/DD/YYYY Format
First Name*
Last Name*
E-mail Address*
Street
City
Daytime Phone
Country
Sex
Female Male

Education
High School College Post Graduate Degree
Field of Study

ChiWalking Experience (Check all that apply)

I have the book & DVD and practice on my own


I have taken the class


Length of Time Practicing:  Months   Years

To what extent do you feel you've learned ChiWalking
form and incorporated it into your walking?

Walking & Fitness Experience
Do you have a regular walking program?
Number of days per week:
Number of minutes per workout:
Other Physical Fitness Certifications/Qualification Check all that apply
AFFA
ACE
NASCM
Personal Trainer
Yoga Instructor
Pilates Instructor
Spinning Instructor
T'ai Chi Instructor
Group Trainer
Other
Other Martial Arts Instructor
 

What terrain do you walk on? Check all that apply
Road
Trail
Dirt Roads
Hills
Track
Treadmills
Have you walked in an event? Check all that apply
10K
5K
Marathon
Half-Marathon
Other
Sources of Fitness Information Check all that apply
Magazines
Websites
Newsletters
Books
Friends
Other
Other Sports You Participate In Pick 5 for most time spent, pick 1 for least time spent.
Running
Walking
Swimming
Bicycling
Other
Other Information

I have Personal Trainer Insurance:

I have Red Cross CPR Certification:

Goals of Becoming a ChiWalking Instructor Please write 250-500 words that describes why you want to become a ChiWalking Instructor:
Teaching and Presentation Skills
I currently present:
I currently present materials about fitness and health to groups on an ongoing basis:
I have never presented materials about fitness and health:
I regularly do public speaking, teaching and presentations:
I have done little public speaking, teaching or presenting:

Interests/Goals I am interested in learning more about the following:
ChiWalking for Seniors:
ChiWalking for Weight Maintenance:
ChiWalking for Pre/Post Natal Women:
Anything Else You Want to Tell UsTell us anything about yourself that has not been covered but that you feel you would like us to know: