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Instructional Offerings - ACA Canoe IDW/ICE Registration Form


Karen Knight
615 Venice
Sugar Land , TX 77478
Bob Foote
615 Venice
Sugar Land , TX 77478


American Canoe Association

Canoe Instructor Workshop Registration and Information Form


Type of Course: Location: Date:


1. Personal Information


Name ____________________________ Date of Birth _________ ACA # __________


Address ______________________________________________________________________

Street______________________ City_________________ State_____ ZIP_________


Telephone number(s) ______________________________________________________________________


E-mail address ______________________________________________________________________



  • Professional Goals and Background


I am seeking certification in:

Briefly describe your paddling experience: ______________________________________________________________________




Describe your teaching and/or leadership experience: ______________________________________________________________________



Why are you seeking ACA instructor certification? ______________________________________________________________________

Please rate your swimming ability: none weak good strong



  • Confidential Medical and Emergency Information


Emergency contact during course _______________________________________________________________________

Name Relationship to you


Telephone Number / Email / Address


Please list any medications you are taking: _______________________________________________________________________


Do you have any medical conditions we need to know in case of emergency? _______________________________________________________________________


If so, please explain: _______________________________________________________________________


Please indicate any medical or environmental allergies, their severity and the treatment plan for each allergy: _______________________________________________________________________


Do you have any physical limitations that could affect your participation in the course?


If so, please explain: ______________________________________________________________________


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