Arthritis Foundation Florida Chapter
Instructor Information Form
CIRCLE ONE: MR. MRS. MS. MR. & MRS. PLEASE PRINT!
FIRST NAME: LAST NAME: MI:
COMPANY (if applicable):
ADDRESS:
CITY/STATE/ZIP: BIRTHDATE: / /
PHONE: ( )___________________ ¨ Home ¨ Work ¨ Cell OTHER PHONE ( )____________________¨ Home ¨ Work ¨ Cell
E-MAIL: ____________________________________________________________________________________________________
Do you have arthritis?
¨ Yes ¨ No ¨ Don't know
Connection to Arthritis?
¨ Father ¨ Mother ¨ Sister ¨ Brother ¨ Friend ¨ Son ¨ Daughter ¨ Other___________________
If Child with JA – NAME: ___________________________________ Age: ______ Birthdate: _______________________________
What type of arthritis do you have?
¨ Osteoarthritis OSTEOARTHRTS
¨ Rheumatoid arthritis RHEUMATOID
¨ Fibromyalgia FIBRO
Other, list ______________________
¨ Don't know type
¨ Doctor never told have arthritis
Have you been diagnosed by a doctor
¨ Yes ¨ No
Please list workshops and certification dates
¨ Arthritis Foundation Aquatic Program
¨ Workshop date _____________
Certification received
¨ Leader - date ______________
¨ Instructor - date ____________
¨ Trainers - date _____________
¨ Arthritis Foundation Exercise Program
¨ Workshop date _____________
Certification received
¨ Instructor - date ____________
¨ Trainers - date _____________
¨ Arthritis Foundation Tai Chi Program
¨ Workshop date _____________
Certification received
¨ Instructor - date ____________
¨ Trainers - date _____________
¨ Arthritis Foundation Self Help Program
¨ Workshop date _____________
Certification received
¨ Leader - date ______________
¨ Trainer - date ______________
PLEASE COMPLETE REVERSE SIDE
Please list the facility information where you are currently teaching:
FACILTY NAME:
CONTACT FIRST NAME: LAST NAME:
TITLE: Assistant's Name:
ADDRESS:
CITY/STATE/ZIP: ________________________________________________________________________________________
PHONE: ( )_____________________________ ______ FAX: ( )______________________________________________
E-MAIL: ____________________________________________________________________________________________________
Please list any facility you know that might be interested in partnering with the Arthritis Foundation:
FACILTY NAME:
CONTACT FIRST NAME: LAST NAME:
TITLE: ____ Assistant's Name: ____________
ADDRESS:
CITY/STATE/ZIP: ________________________________________________________________________________________
PHONE: ( )_____________________________ ______ FAX: ( )______________________________________________
E-MAIL: ____________________________________________________________________________________________________
I am interested in more information about:
¨ Advocacy Program
¨ Arthritis Walk
¨ Jingle Bell Walk/ Run
¨ Joint in Motion Marathon Training Program
¨ Summer Camps for Kids with Arthritis
I would be interested in volunteering for the following committee for my local area:
¨ Programs and Services
(includes Life Improvement Series, Health Fairs and Speaker Board)
¨ Fundraising
¨ Advisory Board
Thank you
Please return to:
Arthritis Foundation, Florida Chapter
3816 W Linebaugh Ave., #303, Tampa Florida 33618
Fax 813-968-1119
Phone: 800-850-9455