Personal Information
	First Name:
	Last Name:
	Address:
	Address 2:
	City:		State OR Province:		Zip Code:
	Daytime Telephone:
	E-mail Address:
Employment Facility Information
	Facility Name:
	Address:
	Address 2:
	City:		State OR Province:		Zip Code:
	Phone:
	Facility E-mail Address:
Program Affiliation Information
	Are you presently affiliated with an Aqua Professional Program and if so, which one?
Training Information
	Where do you teach?
	What type of classes do you teach?
	How long have you been teaching water exercise or providing therapy?