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? ______________