SEIC and ACA Dues Reimbursement Form

The Board of Prairie State Canoeists is very appreciative of all of the work and effort that go into maintaining Instructor certification with the American Canoe Association, and of 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.  During the First year of the program (2004/5, all member/Instructors will be reimbursed.   From then on in January of each year 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 cancelled 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 ______________