Registration Form Please be sure that you have read the registration information and safety page prior to submitting your registration to us. Thank you. Please fill out the form completely as we need some of the information for equipment sizing and your comfort on the water.
Name *	First Last
Address	Street Address Address Line 2 City State / Province / Region Postal / Zip Code Antigua and Barbuda Aruba,Bahamas Barbados Belize Canada Cook Islands Costa Rica Cuba Dominica Dominican Republic El Salvador Grenada Guatemala Haiti Honduras Jamaica Mexico Netherlands Antilles Nicaragua Panama Puerto Rico Saint Kitts and Nevis Saint Lucia Saint Vincent and the Grenadines Trinidad and Tobago United States Argentina Bolivia Brazil Chile Colombia Ecuador Guyana Paraguay Peru Suriname Uruguay Venezuela Albania Andorra Armenia Austria Azerbaijan Belarus Belgium Bosnia and Herzegovina Bulgaria Croatia Cyprus Czech Republic Denmark Estonia Faroe Islands Finland France Georgia Germany Greece Hungary Iceland Ireland Italy Latvia Liechtenstein Lithuania Luxembourg Macedonia Malta Moldova Monaco Montenegro Netherlands Norway Poland Portugal Romania San Marino Serbia Slovakia Slovenia Spain Sweden Switzerland Ukraine United Kingdom Vatican City Afghanistan Bahrain Bangladesh Bhutan Brunei Darussalam Myanmar Cambodia China East Timor Hong Kong India Indonesia Iran Iraq Israel Japan Jordan Kazakhstan North Korea South Korea Kuwait Kyrgyzstan Laos Lebanon Malaysia Maldives Mongolia Nepal Oman Pakistan Palestine Philippines Qatar Russia Saudi Arabia Singapore Sri Lanka Syria Taiwan Tajikistan Thailand Turkey Turkmenistan United Arab Emirates Uzbekistan Vietnam Yemen Australia Fiji Kiribati Marshall Islands Micronesia Nauru New Zealand Palau Papua New Guinea Samoa Solomon Islands Tonga Tuvalu Vanuatu Algeria Angola Benin Botswana Burkina Faso Burundi Cameroon Cape Verde Central African Republic Chad Comoros Democratic Republic of the Congo Republic of the Congo Djibouti Egypt Equatorial Guinea Eritrea Ethiopia Gabon Gambia Ghana Gibraltar Guinea Guinea-Bissau Cote d'Ivoire Kenya Lesotho Liberia Libya Madagascar Malawi Mali Mauritania Mauritius Morocco Mozambique Namibia Niger Nigeria Rwanda Sao Tome and Principe Senegal Seychelles Sierra Leone Somalia South Africa Sudan Swaziland United Republic of Tanzania Togo Tunisia Uganda Zambia Zimbabwe Country
Phone Number	### - ### - ####
Email *
Emergency contact name
Emergency contact number
Age
Height required for gear sizing
Weight required for gear sizing
Swimming ability	Good    Fair   Poor
Previous paddling experience
Expectations from this course
How did you hear about us?
Course Interest	Pool Session   Give it a Whirl   Introductory Course   Advanced Beginner Clinic   Intermediate Clinic   Rolling Clinic   River Rescue for River Runners
Course date
Medical Information
Allergies	Bee stings   Penicillin   Pets
Allergies other
General physical condition	Good   Fair   Poor
Chronic Disabilities	Hearing   Sight   Other
Please specify
Sight	20/20   Glasses   Contacts
Have you ever had any shoulder problems? Please specify.
General questions or concerns you may have

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