ACA L4 Registration: April 10-14 2023 Name(Required) First Last Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email(Required) Phone(Required)Gender Male Female Prefer Not To Say Date of Birth(Required) MM slash DD slash YYYY ACA Membership Number(Required)If you have not yet received your number, please enter a 1 in this field. You must join the ACA in advance of participating in courseOrganization Are you a ACA SEIC member already?(Required) Yes No Current ACA Instructor LevelL2L3L4Other paddlesports training and instructor certificationsPlease describe and include when and whereWhat kayak will you be using for this course (make, model, size)(Required) How many years have you been paddling a whitewater kayak?(Required) What class of whitewater do you feel comfortable leading others on?(Required)Class IClass IIClass IIIClass IVClass VWhat seasons do you normally paddle?(Required) What is your favorite river and level on that river?(Required) How many days a year do you typically paddle a whitewater kayak?(Required) Have you taken a formal Swiftwater Rescue Course? Yes No Currently First Aid Certified? Yes No Are you currently CPR/AED certified? Yes No Any allergies, medications or physical, mental or medical conditions you feel the instructor should know?all answers are kept confidentialEmergency Contact Name First Last Emergency Contact PhoneThe following release and assumption of risk must be read, agreed to and signed on site the first day of class as a condition of participation Agreement(Required) I hereby state that I have read and understood all the information on this form and that my answers are accurate. ACA L4 Kayak Instructor Certification Fee(Required) Price: Total Credit CardCard Details Cardholder Name Δ
