Instructor in Training Application

First Name

Last Name

Phone/Mobile

Address

Address Line 1

Address Line 2

City

State

Zip Code

Date of Birth

Preferred Pronoun

He/Him

She/Her

Them/They

Prefer not to Disclose

Are you a...

A Veteran

VA Staff

Are you a person with a disability?

Select type of instructor certification you are applying for.

What is your professional experience? Please tell us about your current and past professional experience that may relate to becoming a certified instructor.

Please provide a list of degrees or certifications you have.

Please upload your resume.

Choose File

Have you ever been convicted of a felony or a had a domestic violence charge?

Yes

If yes, please explain.

References

Please list two references we can contact on your behalf.

First Name

Last Name

First Name

Last Name

Phone/Mobile

Relationship

Do you have experience working with people with disabilities? If so please explain.

Do you have any martial arts experience? If so please explain.

Is there anything else you would like to share about yourself?

Please give us 2-3 days and times over the next 7 business days that work best for you to interview with us.

I have read and consent to the STRIVE4YOU Background Check Policy.

I further acknowledge that the Instructor Certification application fee is $75 and that this application fee is nonrefundable.

I understand the remaining $600 initial Instructor Certification Fee will be due two weeks prior to attending my in-person ICT. I acknowledge that the VA National Adaptive Sports & Special Events Program’s Adaptive Sports Grant(ASG)may cover the Instructor Certification Fee in full or partial and that I may be responsible for any remaining balance not covered by the ASG. I understand that I have the right to withdraw my application from consideration due to available funding.

Furthermore, I acknowledge that by submitting this application and any associated fee(s), does not automatically enroll me into the Instructor Certification Program and is only a step in the application process.

Signature

Date