American Canoe Association

CK 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: Introduction to Kayaking Basic Coastal Kayaking Open Water Coastal Kayaking

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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