River Safety and Rescue for COO (29Jun-1Jul2019)

Please complete the below form to register for the ICW on June 29, 2019 through May 1, 2019. Mandatory fields are marked with an asterisk (*).

ACA Member Number

Last Name

First Name

Address

City

State

Zip (5 digit)

Phone

(###)

###

####

Email Address

Birthdate

MM

DD

YYYY

Height

CKAPCO uses this information to select appropriate equipment for students.

Weight

CKAPCO uses this information to select appropriate equipment for students.

Add me to CKAPCO's e-mail list?

Yes

No