REGISTRATION FORM

MIDWEST FREESTYLE CANOE SYMPOSIUM, 2007

(Please print.  One form for each person.  Please copy additional registration forms if needed.)

 

Name:___________________________________Phone:___________________

 

Street Address:_________________________________________________

 

City:__________________________ State:_________________Zip:_________

 

E-mail address:__________________________  ACA number_______________

 

I am paddling (Check one) solo____  tandem___  need boat___ need gear_____

                                                                          Need motel information _____          

 Exhibition______:   (Check only if you would like to enter.  Forms will be sent to you with the confirmation information and will be held in conjunction with the National Competition Sat. eve.)

Men’s Solo____        Women’s Solo_____        Tandem______

 

Classes:  (All classes on Sat. 8:30-11:30 a.m., and 1-4 p.m., and Sun. 8:30-11:30a.m.)

(Check level below)                                         (Enter amount below)

____Level 1……………………………………...$80__________     

 

____Level 2………………………………………$80__________      Make checks payable to: 

                                                                                                          Elaine Mravetz

____Level 3……………………………………...$80__________  

                                                                                                          Return registration, waiver,

____Level 4…………………………..………….$80__________       medical form, and payment

                                                                                                           to:

____Level 5..…………………………………….$80__________

                                                                                                                   Elaine Mravetz

____Putting It All Together …………. ………$80__________               6210 Boneta Road

____Kids Class,$30 per Class, Sa., Su. a.m. only_________               P.O. Box 136      

____Competitor Seminar (Fri.—no additional fee)_________              Sharon Center, OH 44274

____Soloing a Tandem (Sat. a.m.)……………$30_________               (330) 239-1725

____River Canoe Trip Leading Training…….$70_________                 rmravet@uakron.edu

____River Canoe Trip Leading Examination.$70_________

___Canoe Camping Endorsement………….. $70________

___Instructor Updates (Canoe, Kayak)……  $70_________

 

Registration and Insurance (Required)..$25________      

Site Admission Fee (Required)…….……$20________                                                                                                                            

Meals:

Friday Supper……………………………………….$9_________

Saturday Breakfast…………………………………$5_________

Saturday Lunch……………………………………..$5_________

Saturday Supper……………………………………$9_________

Sunday Breakfast…………………………………..$5_________

Sunday Lunch………………………………………$5_________

 

Midwest 2007 T-shirt………………….$15________           Size_____

Boat/gear rental, $30 per day ……………________  Size PFD_____

 

Grand Total……………………………..$____________

 

 

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CONFIDENTIAL MEDICAL AND EMERGENCY INFORMATION

 

If unsure of your physical condition or health regarding paddlesports, please consult your physician in advance.

 

Name________________________________________________________________

 

Street Address ________________________________________________________

 

City, State, Zip ________________________________________________________

 

Phone:  Home (     )_____________________  Work:  (     )______________________

              Cell    (     )_____________________

 

E-mail Address:_________________________________________________________

 

 

In case of emergency, please notify:

 

Name__________________________________   Relationship ______________________

 

Telephone:  (     )_________________________ or (     )_____________________________

 

E-mail Address:_____________________________________________________________

 

Do you have any physical condition which might lead to dizziness or fainting?  Yes ___ No ___    If you checked Yes, please elaborate:

 

 

 

Do you have allergic reactions to insect stings or any other source?  Yes___  No ___

If yes, do you carry medication for this?  Yes ___  No ___

If yes, where will it be located?

 

 

Are you currently under a physician’s care?  Yes ___  No ___

If yes, please elaborate:

 

 

 

Please discuss below any conditions that might affect your health or comfort while paddling, any significant dietary restrictions, or any special needs that you may have :

 

 

 

Insurance Information:

Company Name__________________________________________________

Group / ID #  __________________________________________________

Insured Person’s Name __________________________________________