.Form may be duplicated.                                                                                                                                                       
REGISTRATION FORM
NFHS COACHES EDUCATION PROGRAM
12 hour course
8 hour Sport Science w/book and take-home test - 4 hour Sport First Aid w/book and take-home test

Workshop Location: ___________________________________________________________________

Dates: ___________________________________Times: ______________________________________

Name:_______________________________________ Social Security Number_____________________

Check One: Ms. ____Mr.____Dr.____ Sport interested in coaching _______________________________

Organization/Affiliation/Employer: _______________________________________________________

Work Address: _______________________________________________________________________

                            _______________________________________________________________________

Home Address:_______________________________________________________________________

                            _______________________________________________________________________

Telephone: Work: (______)_____________ Home: (______)_____________  Fax: (______)____________

Preregistration and payment is required   by mail at least one week before workshop.
Registration fee $150.00 Check One: Cash ( ) Check ( ) Money Order ( ) Refunds up to 7 days before the event.
Make checks payable to WVSSAC and mail with registration form to:         Note price increase as of 9/1/02.

WVSSAC -- 2875 Staunton Turnpike -- Parkersburg, WV 26104 -- Phone:  304-485-5494 -- Fax: 304-428-5431

According to State Department Policy and Senate Bill I, the participant must have State Department of Education Coaching Authorization to their local Board of Education before they can coach. It is the responsibility of the participant to make sure the county Board of Education has a valid copy of their State Department of Education Authorization.

If you are interested in graduate credit for the NFHS Coaches Education Program  Sports Science and First Aid course offered through the West Virginia Secondary School Activities Commission and West Virginia University, you may request graduate credit information to be sent to you by completing the following:
Course:            NFHS Coaches Education Program Sports Science
Credit Hours:  Two (2)
Cost:                 $33.00 per credit hour for students currently enrolled at WVU
                          $10.00 additional fee if not currently enrolled at WVU
Note: No under graduate students can register. Must have completed bachelor’s degree.

Course Instructor: _______________________________Date(s) of Course: ________________________

Participant’s Signature: ___________________________________(Sign only if interested in graduate credit)
(Graduate course credit and payment information will be sent to you by West Virginia University.)

Submission of this form constitutes class enrollment. - You will be notified only if the class is cancelled.