To apply, please print this form or download it, save and rename using your last name, and email or snail mail to:

Email to: This email address is being protected from spambots. You need JavaScript enabled to view it.

Mail to: Palmetto Paddlers PO Box 984, Columbia SC 29202-0984

 

Application deadline is:

May 31, 2017 for an emailed application 

May 29, 2017 for a postmarked mailed application

Applying for funding for:

ACA River Kayak Instructor ___ 

ACA River Canoe Instructor ___ 

ACA Coastal Kayak Instructor ___ 

ACA Swift Water Rescue Instructor ___ 

 

Name: _________________________________________________________________

Home Address:  _________________________________________________________

City, State, Zip code: _____________________________________________________

Home or Cell Phone:  _____________________________________________________

Email Address: (print carefully) _____________________________________________

1. When did you join Palmetto Paddlers? _____________________________________

2. When did you begin paddling?  ___________________________________________

3. Have you previously taught kayaking, canoeing or rescue?  Yes  ___    No  ___ 

a. What type of course or clinic did you teach ______________________________

b. In what capacity? Lead Instructor ___ Assistant Instructor ___ Other __________  

c. When did you teach _________________________________________________ 

4. Have you ever been the Trip Coordinator or the Contact person for a Palmetto Paddlers club trip?   

Yes  ___   No  ___   If yes, provide details____________________________________________

5. Have you ever taken a Swift Water Rescue Class or a Basic Water Safety Course? 

Yes  ___   No  ___   If yes, provide details____________________________________________

6. What level would you rate your paddling ability? ______________________________________

a. List the rivers or bodies of water that you paddled last year. (Include sections, e.g., Section 4 Chattooga) __________________________________________________________________

b. List the rivers or bodies of water that you paddled more than one year ago.  (Include sections, e.g., Section 4 Chattooga) ______________________________________________________

7. What is your swimming ability?  Basic  ___    Intermediate   ___   Advanced  ___ 

8. What other types of current applicable certifications and or licensures do you hold?

CPR  ___ First Aid  ___ First Responder  ___ 

EMT/Paramedic  ___ WFR  ___ WFR-EMT  ___ 

Licensed Teacher  ___ Life Guard  ___ Other  ___ 

ACA Instructor  ___ Other Medical License  ___ 

If you checked ACA Instruction or Other, please describe here ______________________________

9. Are you an American Canoe Association Member? Yes  ___    No  ___ 

10. Please list any other relevant experience, such as offices or special duties that you have held within Palmetto Paddlers or other clubs.  Extra pages may be attached.

_________________________________________________________________________________

_________________________________________________________________________________

Completion of this form does not automatically qualify you for funding. The Safety and Instruction Committee will review your application and you will be notified of their decision at the earliest possible convenience. If you are chosen to receive funding and successfully receive ACA instructor certification, the club will reimburse you $250 for tuition paid by you.  By signing this form you assert that all of the information that you have given is factual. 

 

Print name: ___________________________________________________________ 

 

Signature: _____________________________  Date:__________________________ 

(You may type your name on the signature line for an emailed application)

 

Palmetto Paddlers encourages all recipients of these awards to coordinate club trips and to assist in club-sponsored instruction programs, such as water safety clinics, paddling instruction, etc.

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