Paddle America Club Event Notification Form

The below form is to be used by an appropriate representative of a Paddle America Club (PAC) to notify the ACA Insurance Department of an upcoming PAC event.

If you have any questions, or require additional information, please contact the ACA Insurance Coordinator.

PAC Event #1
Paddle America Club Name *Name of the PAC
First Name *First Name of individual submitting form on behalf of the above PAC		Last Name *Last Name of individual submitting form on behalf of the above PAC
Email Address *		ACA #
Address Line 1 *Mailing address
City *		State *
Zip/Postal Code *		CountryOptional
Phone Area Code *Area Code		Phone number *7 digit phone number
Please enter the following information in order to notify the ACA Insurance Department about an upcoming PAC Event.
Event Name *Name of the event being organized by the PAC
Start Date *MM/DD/YYYY		End Date *MM/DD/YYYY
Venue *Please name and describe the water or land venue that the event is to be held on.
PAC Event #2
Please enter the following information in order to notify the ACA Insurance Department about an upcoming PAC Event.
Event NameName of the event being organized by the PAC
Start DateMM/DD/YYYY		End DateMM/DD/YYYY
VenuePlease name and describe the water or land venue that the event is to be held on.
PAC Event #3
Please enter the following information in order to notify the ACA Insurance Department about an upcoming PAC Event.
Event NameName of the event being organized by the PAC
Start DateMM/DD/YYYY		End DateMM/DD/YYYY
VenuePlease name and describe the water or land venue that the event is to be held on.
PAC Event #4
Please enter the following information in order to notify the ACA Insurance Department about an upcoming PAC Event.
Event NameName of the event being organized by the PAC
Start DateMM/DD/YYYY		End DateMM/DD/YYYY
VenuePlease name and describe the water or land venue that the event is to be held on.
PAC Event #5
Please enter the following information in order to notify the ACA Insurance Department about an upcoming PAC Event.
Event NameName of the event being organized by the PAC
Start DateMM/DD/YYYY		End DateMM/DD/YYYY
VenuePlease name and describe the water or land venue that the event is to be held on.
PAC Representative Signature
As a representative of the aboved mentioned ACA Paddle America Club (PAC), I hereby agree that the event will be conducted in accordance with all ACA requirements, risk management, and all other rules, guidelines and conditions established by the ACA. I have read and fully understand all sanctioning requirements established by the ACA. I have personally inspected the event site(s) and I attest to the fact that such site(s) were appropriate for use in these events and free of undue hazards.
Signature *Signature of PAC representative		Date *MM/DD/YYYY

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