2014 Exercise Science (Full) Membership Application Form NUCAP

Transcription

1 2014 Exercise Science (Full) Membership Application Form NUCAP For graduates of a NUCAP (National University Course Accreditation Program) accredited exercise science course within the last 2 years. For a full list of NUCAP accredited courses please refer to NUCAP courses. If you have not completed a NUCAP accredited exercise science course please complete the 2014 Exercise Science (Full) Membership Application Form NON NUCAP This application form is relevant for all applicants applying for exercise science membership in Please read the 2014 Exercise Science membership NUCAP application guide prior to completing this form. Please allow 30 working days for assessment of this application and an additional 30 working days should submission of further information be required. Please use the following table as your checklist. ESSA will not assess incomplete applications. BEFORE SUBMITTING THIS APPLICATION FORM PLEASE READ AND COMPLETE THE FOLLOWING POINTS Application page reference Tick when completed 1. Complete personal details (Section A). Page 2 2. Complete payment details (Section B). Include membership payment of $ including GST or $ including GST if you were a student member of ESSA in Please complete the credit card payment details or enclose a cheque or money order made payable to Exercise & Sports Science Australia. If paying by credit card please ensure your credit card is current. Please note, credit card payments attract a merchant fee of 1.5% of the quoted fees. Page 3 3. Complete personal declarations (Section C). Page 4 4. List a professional referee (Section D). Page 4 5. List university qualifications achieved (Section E). Page 5 6. Provide official and final academic transcript/s. Copies must be signed and authenticated by a Justice of the Peace or notary. Provide a letter of university course completion if required. ATTACH TO APPLICATION 7. Complete the statutory declaration (Section F). Page 6 8. Attach work experience/practicum logbook (140 hours) with completed practicum reference form/s (Section G & H). 9. Attach any additional documentation e.g. marriage certificate as proof of name change from that appearing on university qualifications. Pages 7-8 ATTACH TO APPLICATION ATTACH TO APPLICATION Page 1

2 SECTION A Personal details Title Mr Given names John Recent Surname Graduate DOB Graduate101@hotmail.com 27/05/1986 *This is required for your website login Are you of Aboriginal or Torres Strait Islander origin? Yes No Postal address Address 12 Greenway Drive Town/Suburb Hamilton State QLD Postcode 4228 Phone Fax Work address Address Smiths Gymnasium Town/Suburb Brisbane State QLD Postcode 422 Phone Mobile Fax Current employment Trainer Previous position/title Coach at my local baseball club Please indicate your primary, and if applicable your secondary, work sector by placing a 1 (for primary area of employment) and 2 (for secondary area of employment if applicable) in the boxes provided: Federal government organisation Research/education institution Sporting club/institution State government organisation Fitness club/institution Health care organisation Hospital Mining Private company Sporting club/institution Workers compensation agency Student Not currently working On leave Please indicate your primary, and if applicable your secondary, area of employment by placing a 1 (for primary area of employment) and 2 (for secondary area of employment if applicable) in the boxes provided: Page 2

3 Administration/project officer Aged care Chronic disease management Chronic disease prevention Clinical assessments & screening Coaching & athlete development Community health/health promotion Education Fitness industry Hospital Management Occupational health & assessment Rehabilitation case management Rehabilitation service provider Sports science testing Strength & conditioning Workplace health or corporate health Privacy statement: Exercise & Sports Science Australia acknowledges and respects the privacy of its members. All information provided on this form is subject to ESSA s Privacy Policy. Details of this policy can be viewed on ESSA s website ESSA uses and discloses personal information only for our primary functions or a directly related purpose e.g. release of information to organisations including Medicare, Department of Veterans Affairs, private health funds, Workcover, National Health Services Directory and relevant condition organisations e.g. Arthritis Australia release of information via the Find an AEP search function on ESSA s website. If you do not wish for your information to be disclosed please indicate here with a tick. You have the right of access to and alteration of your personal information in accordance with the Privacy Act. Please direct any enquiries you have in relation to this matter to ESSA s Executive Officer on ph SECTION B - Payment details Cheque or money order for $ made payable to Exercise & Sports Science Australia is attached (or $ if a student member of ESSA in 2013) OR Card type (Please select) VISA Mastercard Cardholder s name Expiry of card / month/year) Card number I authorise Exercise & Sports Science Australia to debit my credit card for the amount of $ plus a 1.5% merchant fee. (or $ plus a 1.5% merchant fee if a student member of ESSA in 2013) Yes No By submitting this application I acknowledge that Exercise & Sports Science Australia will debit my credit card for the amount of $55.00 plus a 1.5% merchant fee (non-refundable) should the application be declined or if the request for further information is outstanding for more than 1 month. Signature Page 3

4 SECTION C - Personal declarations Declarations a) I certify that the information supplied on and with this form is true and correct. J. Graduate 12 December 2013 Applicant s signature b) If accepted as an exercise science member of the association I agree to abide by the ESSA Code of Professional Conduct and Ethical Practice. J. Graduate 12 December 2013 Applicant s signature c) I certify that if I am working with clients/human subjects (no matter the type) I will have current professional indemnity and public insurance and hold current first aid and cardiopulmonary resuscitation (CPR) qualifications. J. Graduate 12 December 2013 Applicant s signature SECTION D Professional referee Please provide the name and contact details of a professional referee Title Ms Name M. Smith Postal address GPO Box 12 Brisbane Phone msmith@frogpond.com Qualification Bachelor of Exercise Science Current position/title Director/ Owner at Smith Gymnasium Current employer Capacity in which applicant is known to the referee 6 years Please note that ESSA may contact your professional referee to verify information contained within the application Page 4

5 SECTION E - University qualifications achieved Please complete the following information, listing university qualifications Degree Code University Bachelor of Exercise & Movement Science XN53 University of Australia 2013 Year completed Page 5

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8 SECTION F - Statutory declaration Commonwealth of Australia STATUTORY DECLARATION Statutory Declarations Act Insert the name, address and occupation of person making the declaration I, 1 John Recent Graduate (name), of 12 Greenway Drive, Hamilton, QLD (address) And of Personal Trainer (occupation) make the following declaration under the Statutory Declarations Act 1959: 2 Set out matter declared to in numbered paragraphs 2 The attached documentation accurately indicates how the criteria for necessary and sufficient knowledge, skills and competencies are met in order to fulfil application requirements for exercise science (full) membership with Exercise & Sports Science Australia. I understand that a person who intentionally makes a false statement in a statutory declaration is guilty of an offence under section 11 of the Statutory Declarations Act 1959, and I believe that the statements in this declaration are true in every particular. 3 Signature of person making the declaration 3 John R Graduate 4 Place 5 Day 6 Month and year 7 Signature of person before whom the declaration is made Declared at 4 University of Brisbane on 5 7th of 6 May 2013 Before me, 7 Jane Green 8 Full name, qualification and address of person before whom the declaration is made (in printed letters) 8 (name) Jane Green (qualification) PhD - Full time Tertiary Educator of (address) 1 University Drive, Brisbane, QLD 4000 Note 1 A person who intentionally makes a false statement in a statutory declaration is guilty of an offence, the punishment for which is imprisonment for a term of 4 years see section 11 of the Statutory Declarations Act Note 2 Chapter 2 of the Criminal Code applies to all offences against the Statutory Declarations Act 1959 see section 5A of the Statutory Declarations Act Page 8

9 Competent Not Competent Not able to comment SECTION G - Practicum reference form Reference for: Dear Colleague John R Graduate The above applicant has applied for membership with Exercise & Sports Science Australia (ESSA) as an exercise scientist. Requirements of this membership include a minimum of 140 hours practicum. Please complete the following form based on your experience with the above applicant: Skills and experience In the following table, please provide evidence of the practicum the applicant has gained in the relevant area of exercise science: (expand boxes where necessary) Total hours and dates* Description of Activities Site/location Name and signature of referee 6/1/12-5/5/13 32 hours Delivering outdoor group exercise programs Smiths Gymnasium M.Smith M Smith 6/1/12-5/5/13 19 hours Delivering group cycling classes Smiths Gymnasium M.Smith M Smith 6/1/12-5/5/13 12 hours Preparation - planning the group outdoor and cycling sessions Smiths Gymnasium M.Smith M Smith 6/1/12-5/5/13 7 hours Delivering one on one exercise sessions Smiths Gymnasium M.Smith M Smith Total 70 hours *Clinical supervisor: student ratios may be up to 1:5, with the proviso that there must be some 1:1 contact for each placement. Declaration: (To be completed by the supervisor) I certify that the information supplied is true and correct Title Mrs Name Background in exercise physiology (brief summary only): M Smith 5/5/14 Signature M. Smith I m an AEP Bachelor of Exercise Science ( Oxford, 2005), 7 years full time work experience running own fitness business with healthy clients and moderate risk clients. Phone msmith@frogpond.com Fax Please attach this form to practicum logbook Page 9

10 SECTION H - Exercise Science Practicum/Work Experience Logbook (Apparently Healthy) Number of Hours 6/1/12 1 hour 3/4/12 30 mins 15 mins TOTAL: 1 hour 45 TOTAL = 1 hour Case Description Description of Services Supervisor Supervisor s Applicant s Signature Signature Conducted an outdoor group fitness session. Instructed a M.Smith M Smith Tim Shore cardio warm up of jogging and stretching for 10 mins. Demonstrated circuit aerobic activities (such as step-ups, ladder runs & burpees) and resistance exercise using body weight, medicine balls and dumbbells (such as chest press, tricep dips & push-ups). Motivated clients during the circuit class as well as illustrated appropriate techniques. Varied the levels of exercises to suit differing fitness levels such as level 1, 2 & 3 push-up modes (45 mins). Instructed the cool-down with stretches (5 mins). 6 adults (2 male, 4 female) aged between years. All apparently healthy with goals to increase fitness levels. Group stationary cycling class y.o. males and females. All completed PARQ - no health conditions Design exercise session. Plan exercise stations, including both aerobic & resistance exercises. Ensure that exercises chosen can be modified for varying fitness levels. Find a large grassed area with some shade in park. Set-up each circuit station with weights, mats, balls etc ready for outdoor exercise session. Led the set format class, spoke to new comers before the session told them to only do half the increases of the rest of the group, stay under 14 on RPE scale, let me or assistant instructor know if they weren t feeling well. Described challenges for more experienced class members. Gave verbal feedback regarding bike technique to class members. M.Smith M Smith Tim Shore 5/5/13 TOTAL = 1 hour 64 y.o. female, taking medication for high cholesterol (4 years), cleared by AEP to be treated as apparently healthy Took client through the program pre-written by supervisor (AEP). Incremental warm-up on treadmill, 20 min aerobic walking varying hill incline throughout. Monitored RPE, facial expressions and colour. Resistance program: wall push-ups, fitball squat, theraband hip abduction/adduction, balance activities, dumbbell bicep curls, tricep pushdown, abdominal bracing and flexibility. SECTION H - Exercise Science Practicum/Work Experience Logbook (Sports Science/Sports Performance) M.Smith M Smith Tim Shore Page 10

11 15/5/13 to 25/6/13 Number of Hours Testing = 8 hours Program design = 1 hour Case Description Description of Services Supervisor Supervisor s Applicant s Signature Signature Group of 24 women aged Strength and conditioning training for QLD women s state L. Citizen L Citizen Tim Shore between 17 and 21 years old. development program (U21 s) hockey team. My role initially Strength & conditioning involved assessing and recording fitness data for the team (preseason). training program for sports These tests included: weight (digital scales), height team. (stadiometer), BMI, body composition (skinfolds), muscular strength (3RM chest, legs, arms, abdominals) and aerobic fitness (VO2max). All data was recorded and entered into the computer. This information was then used to design and implement conditioning programs to maximise the strength, power and endurance performance of the team. It also aims at preventing injury. I was involved in developing the exercise program with the head coaches & health professionals as well as assist with the implementation and delivery. 20/5/13 Program 2 x 1 hour per week (4 weeks) = 8 hours TOTAL: 17 hours TOTAL 18 x y.o. males, senior football players, no health conditions At the gym my duties were to assist with exercise technique, ensure safe use of machines, and collect RPE data. The strength and conditioning sessions mainly involved aerobic, resistance and flexibility exercises being progressively overloaded from the previous session. The modes of exercise altered to maintain interest & incorporate cross training. Plyometric and power exercises (anaerobic) were sometimes added into the exercise programs. Please refer to the two attached example programs for a more detailed description. All players were fitted with a shoulder harness with the GPS monitor fitted between the shoulder blades to obtain match data. (30 mins) Following the match, data from all units were downloaded into the GPSports analysis software to prepare individual player reports including: total distance, total match time, maximum speed, average speed, acceleration and time spent in 5 different speed zones (1 hr). This data was then given to the head strength and conditioning coach who uses this information to help determine training loads that are L. Citizen L Citizen Tim Shore Page 11

12 1.5 hours appropriate for different playing positions. SECTION H - Exercise Science Practicum/Work Experience Logbook (Exercise and Sports Science Research) 8/4/13 and 9/4/13 1/11/13 and 8/11/13 Number of Hours 6 hours per day (approx 3 hours per subject) TOTAL: 12 hours 2.5 hours per day Case Description Description of Services Supervisor Supervisor s Applicant s Signature Signature I was a research assistant for an investigation into truck S. Brown S Brown Tim Shore activation during golf swing. My role was to collect and record data for four subjects. These included taking height and body mass. It also included setting up each subject with surface EMG on their erector spinae, external obliques, rectus abominus and latissumus dorsi. This involved shaving and cleaning the skins surface with alcohol and placing the pairs of bipolar surface electrodes on both sides of the body. Reference electrodes were also positioned over spinous processes. Each subject was then instructed to perform a total of 15 golf swings with a driver. This was conducted every 2.5 minutes to eliminate fatigue. During this time, my roles were to continuously monitor positioning and contact of electrodes on the truck as well as monitor quality signal from the EMG. I also had to upload the collected EMG data onto the study laptop into the appropriate folder as well as check the figures to ensure that a retrial did not have to be undertaken. When all the swing trials were completed, I removed the electrodes from the subject & disposed of them. Four amateur male golfers aged 22, 25, 23 and 27. Data collection for a research study into back muscle activation during golf swing. An elite male triathlete aged 27 years old. No current injuries. I assisted an accredited exercise physiologist conduct two separate V0 2 max tests with blood lactate on an elite triathlete in our university laboratory. These were conducted one week apart. The testing was conducted to determine training zones/ranges. Pre-test assessments: My role was to assist with the set-up and conduction of the V02 max test, as well as take weight, height and body composition measurements before the first test. The BodPod was used to S. Brown S Brown Tim Shore Page 12

13 measure body composition. I calibrated the machine and ensured the subject was dressed appropriately (cap & nose plug), then sat with the AEP at the computer whilst the testing was undertaken (5 minutes). V0 2 max test: For both tests (cycle and treadmill) we used the CosMed K4B2, which is a portable and mobile V02 testing unit. I was responsible for calibrating the device, setting up the machine to collect heart rate and gas exchange, placing the device on the subjects back and ensuring the face mask had a good seal around the nose and mouth. Once the test had commenced, it was my duty to progressively increase the speed of the treadmill (2km/hr every 2 mins) or load on the bicycle (50 W every 3 mins). I also took blood lactate measurements every 30 seconds before the end of each stage (using lactate pro machine). At completion of the V02max test, I removed all equipment attached to the subject. TOTAL = 5 hours Results: Height (cm):176cm Weight (kg): 65kg (cycle) 64.5kg (treadmill) Body composition (% fat): 8% Duration of V0 2 max test: 15 mins (cycle), 14 mins (treadmill) HR max (bpm): 193 (cycle), 195 (treadmill) VO 2 (ml/min/kg): (cycle), (treadmill) VC0 2 (ml/min): 3878 (cycle), 3700 (treadmill) SECTION H - Exercise Science Practicum/Work Experience Logbook (Workplace Health) Number of Hours 4/6/12 TOTAL = 5 hours Case Description Description of Services Supervisor Supervisor s Applicant s Signature Signature Workplace fitness assessment Took office workers through fitness tests set up in their M.Smith M Smith Tim Shore for 5 workers (approx one boardroom. The testing involved the following measurements: hour per client with height discussion). weight Client 1: 32 y.o. female, waist and hip girth measurements healthy sit and reach flexibility Page 13

14 Client 2: 56 y.o. male on medication for hypercholesterolemia for 2 years Client 3: 26 y.o. male, nil health issues Client 4: 47 y.o. female. Osteopenic Client 5: 39 y.o. female, healthy and very active. shoulder flexibility 7 level abdominal test 5 min Harvard Step test After each testing session, BMI, waist to hip ratio and step test result were calculated. The client was taken through their results and compared to the available norm values. From these results, recommendations were made regarding an exercise program. Client 1 - had reduced shoulder flexibility and was shown some upper body flexibility exercises Client 2 - performed well on all tests and gave advice about cross training to vary from his usual daily walk Client 3 - scored very high on step test but poorly on flexibility and abdominal tests. Provided hamstring, lower back and upper body stretches as well as bracing activities to work on abdominal strength Client 4 - body weight resistance exercises were shown to help maintain bone density Client 5 - she is training for her first half marathon so a six month training plan was devised for this client. SECTION H - Exercise Science Practicum/Work Experience Logbook (Hospital/Clinical Services) 12/7/12 to 9/12/12 Number of Hours 12 x 1 hours sessions Case Description Description of Services Supervisor Supervisor s Applicant s Signature Signature Males and females aged Prepared client measuring resting blood pressure and set up 12 lead M.Smith M Smith Tim Shore Cardiac investigation stress test ECG leads, gave instructions about the format of the test and how to (have completed unit EX315 walk on the treadmill if they weren t familiar. The Bruce protocol was covering BP and ECG analysis) used in these testing session and was performed with a Cardiologist present. My role during the test was to control the treadmill. The cardiologist would discuss any abnormal ECG rhythms with me afterwards and expect me to explain what I thought the arrhythmias were and how they may affect exercise and was it appropriate if they were to participate in exercise. Page 14