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INSTRUCTORS REGISTRATION 
Section 1: Information
Previous Paddling Experience:
ACA Membership number (If applicable)
ACA Instructor Certifications in:
How did you hear about the course?
Section 2: Requirements
Essential Eligibility Criteria to participate in this course:
In order to participate as an instructor or assistant instructor in the Adaptive Paddling Workshop,
each individual must meet the following criteria:
•Be 18 years or older, or accompanied by an adult.
•Be able to manage all personal care and mobility independently or with the assistance
of a companion who accompanies the participant.**
•Be able to get in and out of a canoe or kayak independently or with the assistance
of a companion.
•Have prior experience paddling a canoe or kayak, paddling safely on flat water.
•Be able to perform a wet exit independently.
•Be able to re-enter the canoe or kayak following a deep water capsize independently,
or with the assistance of one other paddlecraft.
** NOTE: If a companion accompanies a participant and also participates fully in the instructional activities, the companion may be charged as a participant, at the discretion of the sponsoring organization.
Check one:
I have read the above essential eligibility criteria and will be able to
participate fully in the class.
I have questions about the essential eligibility criteria and would like to speak
with someone from this course.
Signature: ___________________________________
Date: ____________________
Section 2: Payment Information
Course fee: Only $ 379.00
Make Checks Payable to
Red River Division of the ACA
Mail form including registration fee payment to:
Red River Division, 381 Casa Linda Plaza, TMB 311, Dallas, TX 75218
You will receive registration Confirmation and Location information upon receipt of program fees.
If you have specific needs or questions, please contact Mike Swope in advance.
www.TexasAPW06.homestead.com 214 -669-1663 mike.swope@gmail.com
STUDENT REGISTRATION
Please read the following information before completing your registration for this course:
Essential Eligibility Criteria to participate in this course:
In order to participate as a student in the Adaptive Paddling Workshop, each individual must meet the following criteria:
·Have a significant mobility impairment that limits the ability to participate in recreation activities.
·Be able to breath independently, not require medical devices to sustain breathing.
·Be able to hold head upright without neck / head support.
·Be able to maintain a closed mouth / lips while under water.
·Following instruction in the pool, be able to independently turn from face down to face up and remain floating face up while wearing a properly fitted personal floatation device (life preserver).
·Be able to manage personal care independently or with the assistance of a companion* (friend or family member) who accompanies the individual.
* at no cost to the hosting / sponsoring organization
Check one:
o I have read the above essential eligibility criteria and will be able to participate fully in the class.
o I have questions about the essential eligibility criteria and would like to speak with someone from this course.
Please complete the following
Confidential Participant Information
and mail it to Mike Swope
BY March 1
Call 214-669-1663 with any questions.
Canoeing / Kayaking is a strenuous activity. If you have any questions regarding your health and participation in canoeing / kayaking, please discuss it with your physician. We ask you the following information to be aware of any potential problems and to help you enjoy safely the sport of canoeing / kayaking. Please use additional paper in necessary.
Height: Weight: Date of Birth / Age:
Section 1: General questions
Describe your swimming ability:
Describe your canoeing / kayaking experience:
How would you describe your general health:
Section 2: Medical Information & History
Have you ever had? (please check the Yes or No column)
ConditionYesNoConditionYesNo
High Blood PressureBack Problems
DislocationsDo you have muscle spasms
If Yes…what triggers them?
Do you get cold easilyAre you greatly affected by heat
Are you pregnantAre you taking medication
Are you allergic to any medicationAny side effects of medication such as sun sensitivity, fatigue, etc.?
Are you allergic to insect bites or bee stings
If Yes…do you carry medication?Seizures
If Yes…what triggers them?
If Yes…date of last seizure?
If you answered Yes to any of the above items, please explain below:
Do you have a disability? If yes, please describe:
How long have you had the disability?_______
Do you have a mobility impairment? If yes, please describe:
Do you have a sensory impairment (sight, sounds or sensation)? If yes, please describe:
So that we can better understand your needs, please list any medical, physical, psychological or emotional issues not mentioned above:
Insurance Information:
In Case of Emergency - Please contact:
Phone (day): Phone (day):
Phone (eve): Phone (eve):
Section 3: Waiver and Release
Please download and sign and return with payment and registration documents.
