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: _______________________________________________________________