ALBERNI VALLEY MINOR HOCKEY ASSOCIATION COACHING APPLICATION

NAME: __________________________________________________________________________

                        (Given)                                                   (Middle)                                       (Surname)

 ADDRESS: _________________________________________ Postal Code ______________________

HOME PH # _________________WORK PH # ___________________ CELL PH # __________________

FAX # ___________________________ EMAIL: ___________________________________________

EMPLOYER: _____________________________________OCCUPATION: _______________________

EMPLOYER ADDRESS: _________________________________________ PH # __________________

 Preferred Coaching Assignment (Indicate “F” for female, “1” for first choice and “2” for second choice)

                        Recreational      Rep                                          Recreational      Rep

Mites               ______           N/A                    Pee Wee        ______           ______

Novice            ______           N/A                    Bantam           ______           ______

Atom               ______           ______           Midget            ______           ______

Certification/Training – NCCP (National Coaching Certification Program)

                                                            Yr Completed                Location           

NCCP Theory 1                     ______                       ___________________

NCCP Theory 2                     ______                       ___________________

Initiation Program                  ______                       ___________________

Coach Level                          ______                       ___________________

Intermediate Level                ______                       ___________________

Advanced Level 1 or 2         ______                       ___________________

CHSP                                     ______                       ___________________

Speak Out                              ______                       ___________________

Checking Clinic                     ______                       ___________________

Other Coaching Courses or Training: 

________________________________________________________________________________

 ________________________________________________________________________________

Hockey Coaching Experience – List in order, starting with most recent

Year                   Association/Team Name                                    Age Group         Position

 ______           _______________________________  ________      _________________

 ______           _______________________________  ________      _________________

 ______           _______________________________  ________      _________________

 ______           _______________________________  ________      _________________

 ______           _______________________________  ________      _________________

Other Sports:

Year                   Sport                                        Association                                           Age Group

 ______           _________________          _______________________        _________

 ______           _________________          _______________________        _________

 ______           _________________          _______________________        _________

Playing Experience – List in order, starting with most recent

Year                               Association                                                       Age

 ______                       ______________________________     ______

 ______                       ______________________________     ______

 ______                       ______________________________     ______

1. I hereby consent to disclosure of the above information.
2. I hereby acknowledge the authority of the district and local minor hockey associations to carry out and abide by their constitution, bylaws, rules and regulations.
3. I hereby acknowledge that I have read and understand the coach’s role as outlined in the Coaches Code of Conduct.
4. I hereby agree to familiarize myself with the National Coaching Certification Program (NCCP) requirements for coaching minor hockey and ensure that I maintain the required level of certification.
5. By way of this application, I give permission to Alberni Valley Minor Hockey Association to peruse a criminal record search on myself.

            Signature: __________________________________________________ Date: ______________________