Instructional Offerings - ACA Freestyle | Touring Canoe IDW/ICE Registration Form |
American Canoe Association Touring Canoe/Freestyle 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 _________________________________________________________
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
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: ______________________________________________________
|
Bob and Karen trust WebDesignByJason.com to create and maintain this site |