Instructional Offerings - Registration Information |
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 ___________________________________________________________
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
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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