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: __________________________________________________________________________