The Prairie State Canoeists board of directors appreciates all of the work and effort that go into maintaining instructor certification with the American Canoe Association, and the contribution that certified instructors make to the club.  As a token of our appreciation, the board has authorized yearly reimbursement of SEIC and ACA dues for all certified ACA Instructors who are Prairie State Members, and who have participated in the instructional program or led one trip during the preceding year.  In January, the Instructional Coordinator will submit a list of Instructor/Members who are eligible to the Treasurer.

Reimbursement will be for a maximum of $55, on a first-come first-served basis up to the budgeted amount of $550.

Instructors will be reimbursed upon presentation of this form and their canceled check or receipt. This form must be filled out and submitted by all ACA Certified Instructors who wish to be reimbursed for their SEIC / ACA dues.

Name (printed) ___________________________________________

Address ___________________________________________________________

Phone ________________________________

Email ________________________________

Level of ACA certification _________________________

ACA Number _________________

Amount of ACA dues ________________

Signature _________________________________________

Date _______________

Approved by Training Coordinator ______________________________

Date ______________