*Manuals and Study Materials are Non-refundable & are required for enrollment in the certification.
Agreement for Enrollment Signature__________________________________________________
I understand that I am responsible for completing the class I am registered for. I understand that for the distance learning program the study materials and manual are non-refundable. In the event, I cannot complete the course due to medical reasons, I will only receive a refund of certification cost (not study materials) if the written exam has not been mailed to the proctor. If the written exam has already been mailed by my request, then my refund would be $15 than the certification to cver mailing and material cost of the test. Proof of medical problem will be required.
Make Check or Money order Payable to A-PAI
547 WCR 18 Longmont, CO 80504
______Check here if you want to use a credit card and we will call you for the information when you e-mail or mail this form.
Your Name_______________________________ Proctor’s Name_________________________________
Home Phone ( )__________________Work Phone ( )__________________
Fax ( )__________________E-mail_____________________________
Circle one of the Options
CORE Aquatic Certification ($100) Manual and Study Materials*($75)
Total for Certification $175
Option for Land and Water
Combined Land & Water Certifications ($125)Manual and Study Materials*($125)
Total for Certification $250
Plus $15 shipping in the Continental US. Otherwise call for shipping estimate.