P.R.I.D.E. Recertification Program: Participant Profile Form

Instructions: Please fill out all the fields and click on the Submit button at the bottom of the form.

Name for name badge:*

Name on certificate:*

Contact Information

Name*

First Last

Email*

Title*

Official Company Name:*

Company Phone*

Cell Phone

Company Fax

Special Requirements

Special Requirements (e.g. dietary, transportation, health, other) – For specific dietary/health requirements, include all details and specific food preferences. If details not provided in advance on this form, dietary arrangements with the caterer will not be made:

Supervisor Name:*

Supervisor Cell:

Supervisors Email*

Emergency Contact Name:*

Emergency Contact Phone*

Company Address

Company Address*

City*

Postal Code*

Province*

Contact Information Consent*

Yes
No

Do you want your contact information to appear on the registrant list for networking amongst course attendees and master trainers participating in your program?

PLEASE SPECIFY THE ORIGINAL CERTIFICATION TRAINING THAT YOU RECEIVED:

a) Professional Instructor in Driver Education (P.R.I.D.E.) Program*

Yes
No

b) Ontario Safety League (OSL)*

Yes
No

c) Infrastructure Health and Safety Association (IHSA) – Formerly THSAO*

Yes
No

Other*

Yes
No

Specify*

please specify eg. transport truck, ambulance, fire truck, heavy equipment, etc.)

ARE YOU AN INSTRUCTOR FOR:

a) School Bus*

Yes
No

b) Highway Coach*

Yes
No

c) Transit Vehicle*

Yes
No

d) Special Needs Vehicle*

Yes
No

e) Other*

Yes
No

Specify*

please specify eg. transport truck, ambulance, fire truck, heavy equipment, etc.)

WHAT YEAR DID YOU RECEIVE YOUR MTO SIGNING AUTHORITY?*

WHEN YOU RETURN TO YOUR COMPANY AFTER ATTENDING THIS PROGRAM, WHAT VEHICLES WILL YOU BE AN ON-BOARD INSTRUCTOR FOR?

a) School Bus*

Yes
No

b) Highway Coach*

Yes
No

c) Transit Vehicle*

Yes
No

d) Special Needs Vehicle*

Yes
No

e) other*

Yes
No

Specify*

please specify eg. transport truck, ambulance, fire truck, heavy equipment, etc.)