1. First Name Last Name

2. Email Address

3. Your Swim School Name and Address:

4. Swim School Telephone:

5. Your cell phone (in case we can't reach you another way):

6. For which training are you registering?

Please Select One ----> Full Training One-day Part of the Full Training Extended Training

7. If registering for part of the Full Training, which part are you registering for?

Please Select One ----> Part 1 Parts 1 and 2 Part 2 Parts 2 and 3 Part 3

8. What do you hope to gain from the training?

9. Your experience teaching swimming (or other topics) (# years for both):

10. Your experience teaching swimming to adults (# years):

11. Certifications (WSI, CPR, etc.):

12. What is your goal for (teaching) adult students who are afraid in water?

13. What would you like to add to your knowledge about teaching afraid adults?

14. Is there anything missing, in your opinion, from the training you received to teach people who are afraid?

15. What's the main thing you've learned about working with afraid adults?

16. What percentage of your clientele is adults?

17. What percentage of your clientele is afraid students?

18. What percentage of your clientele would you LIKE TO BE adults?

19. What percentage of your clientele would you LIKE TO BE afraids?

20. What is the depth range of the pool you teach adults in?

21. What is the temperature of the pool you teach adults in?

22. Once you're licensed, you or your school will determine the price of the Afraid in Water classes that you teach. Are you comfortable with this?

The Training continues with monthly teleconferences for 12 months after the your 9-day training. Requirements for being licensed are:

• Commitment to the Miracle Swimming course content
• Sending your class feedback forms to MSI after each class, for discussion with you
• Positive class feedback
• Timely payment of all fees
• Successful completion of all Full training
• Agreeing to, and signing the Licensing Agreement
• Ongoing participation in teleconferences and interaction with MSI to refresh and update your training

PROPRIETARY NATURE

The method and materials in this training constitute a paradigm shift in teaching. They may be taught only to other instructors within your employ at your swim school. However, these instructors will not be MSI licensed instructors. It is understood that the course materials are proprietary. They may not be duplicated in any form except for the restricted use of instructors at your swim school. All names of such instructors shall be sent by you to MSI in order for MSI to maintain a list of who has this proprietary information.

Do you agree to this, and to maintain the proprietary nature of the MSI
teaching?

Yes No

INTEGRITY OF TEACHING SYSTEM

The teaching is currently understood to be intact and complete. It shall not be changed in any way except by proper protocol with MSI. If a change is deemed helpful by MSI and the body of licensed instructors, the subsequent inclusion of any changes shall be made by all licensed instructors so that the same information is taught in all locations (worldwide) for the sake of consistency and quality control.

Do you agree to this? Yes No

SATISFACTION GUARANTEED OR YOUR TRAINING FEE BACK

We guarantee that our training program will significantly increase the effectiveness of your instruction for adults who are afraid in water. If you follow our system, teach a Miracle Swimming class, and do not attain satisfactory results, you may request and receive a full refund of your training fee. Request must be made within 2 months of the end of 9-day training course.

True False
I am responsible for my experience. In other words, I create my own reality.

After submitting this form, please go to the link on the Full Training web page to submit your deposit payment.