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Instructional Offerings - 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 _________________________________________________________


  • 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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