United States Canoe Association Instructor’s Certification Course
Please Register before July 21 for course at Nationals

Date: ____________________
Current USCA Member (membership is required): Yes or No (Circle one)

Name: _________________________

Address: _____________________________________________

City: ______________________ State: ________Zip___________

Phone: _______________ Fax: _______________ E-mail: ____________________

T-shirt Size:  S,  M,  L,  XL, or  XXL  (Circle one)

RETURN FORM WITH
$100.00 Enrollment Fee and Copies of CPR and First Aid Certification TO:
 Gustave (Tave) Lamperez
24 Roosevelt Street, St. Charles, IL 60174
E-mail: lamperez@netscape.net Phone 630-584-6931
Please Register before July 21 for course at Nationals
__________________________________________________________________
To be filled by Instruction coordinator:

Enclose: 1) $100.00 Enrollment fee _______________Check # ___________Date

2) Photocopies of CPR & First Aid Cards received ___________________

1) ( ) Instructor’s Manual

2) ( ) T- Shirt

3) ( ) First Aid Kit

4) ( ) USCA Video

5) ( ) Certificate

6) ( ) other ____________________________________
Comments:

Date Tave sent check to USCA, Treasurer: ___________ Processed by:_______________