to the ILTP™ Training Center Application

Submit by E-mail
International Lifeguard Training Program
Print Form & Fax
TM
Training Center Application
Directions:
Complete all requested information on both pages using Adobe Acrobat Reader 8.1 or later. Once complete, click on
the "Submit by E-mail" button on the upper right corner or the "Print Form & Fax" to fax the document.
Organization Information:
Organization Name:
Organization Type:
(Mark all that apply)
Government
Educational Institution
City or County / Park & Recreation District
Corporation, LLC, Partnership
Sole Proprietorship / Individual
HOA / Community Association
Members Only Club
Other / Additional:
(Please Specify)
NO
Has your organization worked with Jeff Ellis & Associates, Inc. In the past?
YES
(If YES, please specify below):
Client participant in the E&A Comprehensive Aquatic Risk Management Program
ILTP Training Center
Accident Investigation
Facility / Attraction Inspection
Litigation / Expert
Aquatic Safety Audits
Start date of work:
End date of work:
(Begin date of Agreement)
(End date of Agreement)
JEM Facility Management
Consultant
Reason work ended:
Staff Information:
Primary Contact:
Position / Title:
(Daily Operational Contact)
Office / Daytime Phone:
Office Address:
Secondary / Cell Phone:
Fax:
E-Mail Address:
Training Credentials
Currently Held:
(Mark all that apply)
Other Certifications:
(Mark all that apply)
E&A ILTP Lifeguard Instructor
StarGuard Lifeguard Instructor
JES Program Coordinator
ARC WSI
ARC Lifeguard Instructor
NASCO Lifeguard Instructor
YMCA Lifeguard Instructor
EMT/Paramedic
CPO/AFO
CPRP
Lifeguard (any org.)
Water Fitness Instructor
Other (Specify):
Secondary Contact:
(Person to contact when
primary contact is unavailable)
Office Address:
Position / Title:
Office / Daytime Phone:
Secondary / Cell Phone:
E-Mail Address:
Fax:
Organization Principal / Executive Manager:
Position / Title:
(Individual who has authority to enter organization into a binding contract)
Office Address:
CPR/First Aid Instructor
Office / Daytime Phone:
Secondary / Cell Phone:
E-Mail Address:
Jeff Ellis & Associates, Inc. | 508 Goldenmoss Loop, Ocoee Florida 34761 | 1-800-742-8720 | www.jellis.com
Fax:
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Facility Information:
Aquatic Facility Grouping:
Number of Aquatic Facilities:
Single Facility (year round operation)
Single Facility (seasonal operation)
Multiple Facility (year round operation)
Multiple Facility (seasonal operation)
Year round Facilities:
Aquatic Facility Specifics (PRIMARY FACILITY -
Seasonal Facilities:
to add additional facilities, please use the supplemental facility form):
Facility Name
Phone:
Year round Facility
Contact:
Facility operations
begin on:
Seasonal Facility
Facility operations
end on:
Normal Hours
of Operation:
Address:
Closures /
Holidays
Previous Year / Season Training Information:
Lifeguards
Trained:
Training Program used:
Lifeguard
Instructors Trained:
Training Program used:
Swim Lesson
Instructors Trained:
Training Program used:
Swim Lessons
(Courses):
Training Program used:
CPR/First Aid
Courses:
Training Program used:
Other Courses /
Training:
Training Program used:
Intended Scope of ILTPTM Training Information:
Single or Multiple ILTP Instructor(s) employed by organization, providing community course completion training for the purposes of staffing and
revenue generation for organization on an as needed basis. Organization responsible for all contractual obligations as an ILTP Training Center.
Organization will be responsible for all insurance coverage deemed appropriate for courses offered. Training Center Agreement will detail specific
requirements.
Single ILTP Instructor acting as an independent contractor for one or several organizations for community course completion training on an as
needed basis. Individual ILTP Instructor responsible for all contractual obligations as an ILTP Training Center. Individual will be responsible for all
insurance coverage deemed appropriate for courses offered. Training Center Agreement will detail specific requirements.
Payment:
PRIMARY ITEMS FOR PAYMENT (When service performed or when ordered at current ILTP Training Center prices):
- Annual Provider Fee
- ILTP Training Center Review (one review required annually, additional reviews can be requested)
- Course Completion Kits (Textbook and Certification kit or Online Code and Certification kit)
Payment Terms:
- Pre-payment with credit card or net 30 day invoice with a credit card on file. MUST BE ADDED BELOW.
- Shipping and Handling charges also apply, based upon product delivery requested at the time of order.
CREDIT CARD INFORMATION
(All ILTP Training Centers must have a valid credit card on file).
3 digit security code
on back of the card:
Card Number:
Expiration
Date:
Cardholder Name:
Acknowledgement and Agreement:
By signing below (including electronic signature) the applicant agrees that the information provided within this application is accurate, to the best of
the applicant's knowledge. The applicant further acknowledges that no agreement of services will be concluded by submitting this application, and
that only an official agreement, signed by an authorized officer or employee of your organization and accepted by Jeff Ellis & Associates,Inc. will
constitute an official agreement. Jeff Ellis & Associates, Inc. reserves the right to deny any application submitted, for any reason. Upon notification of
acceptance of the application, the applicant organization must execute a formal agreement for services to begin.
Organization Representative Name:
Organization Representative Signs here:
(Electronic signature)
Jeff Ellis & Associates, Inc. | 508 Goldenmoss Loop, Ocoee Florida 34761 | 1-800-742-8720 | www.jellis.com
Position /
Title:
Date:
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