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: ______________________________________________________________________