ACA Certification Course Report Form

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This form is to be submitted with all associatied fees, by the head instructor trainer/ITE within 30 days of course completion. Only one certification course can be reported per report form. You will have the opportunity to upload the Course Roster below. You can click on the Course Roster link to save it to your computer and fill it in before continuing.

Certification Course Information Key for Reference.

Assisting Instructors
Course Name *
Course Dates *
Venue/Waterway *		City/State *
Program Coordinator *
Head Instructor: First Name *		Last Name *
ACA# *		Email Address
Phone Area Code		Phone
Address Line 1		Address Line 2
City
Location		Zip/Postal Code
If this course was taught by an IT/ITE, update credit can be given to assisting instructors. To issue this update credit, please note below and include the level of update. His/her name and update information should also be listed on the course roster.
NameAssisting Instructor		ACA#1
Update1		Level1
NameAssisting Instructor #2		ACA#2
Update2		Level2
NameAssisting Instructor #3		ACA#3
Update3		Level3
Insured? *Was this course covered by ACA Insurance?
Insurance
If this course was insured by ACA Insurance, please send the original, unaltered ACA Waiver and Release of Liability forms for each participant and instructor to the ACA National Office. Please reference this Submission when sending in the waivers. Thank You
Paddle America Club? *Was this course conducted through a Paddle America Club/ACA Affiliate?
Club/Affiliate NameIf yes, please note the Club/Affiliate name.
ACA Member Participants *		New-ACA Member Participants *
Total Amount Due *Total amount of event and membership fees due.		Payment Type
Membership Fees
All Certification Course participants are required to be current ACA Members. If non-ACA Members participate, annual ACA membership and SEIC registration fees must be paid before we will process this report.
Course Roster UploadYou can upload the Course Roster here.
IT Evaluations UploadThe Evaluation forms can be scanned in and uploaded here. If you are unable to scan them, they must be faxed to 888-229-3792, or sent to: 503 Sophia St, Suite 100, Fredericksburg, VA 22401
Candidate Evaluations UploadThe Evaluation forms can be scanned in and uploaded here. If you are unable to scan them, they must be faxed to 888-229-3792, or sent to: 503 Sophia St, Suite 100, Fredericksburg, VA 22401
Waiver UploadUpload for ACA Waivers

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