1. Please complete the following information in BLOCK CAPITALS and return it to

  1. You will then receive an email back within 7 working days to confirm if you have been successful in gaining a place on the GB Coaching Club

Workshop Choice and Payment *

Date / Location / Workshop Title
Number of workshops attending (£40 each):
Total Cost:

Please ensure that a reference number is included for every payment, both online, by cheque or by credit/debit card. Template of reference number is the following:

COACHCLUBS followed by initial and surname of the attending coach.For example:

John Smith – COACHCLUBSJSMITHSusie Jones– COACHCLUBSJONES

REFERENCE NUMBER: ......

CREDIT/DEBIT CARD - THIS IS ONLY AVAILABLE FOR PAYMENTS OF £10 OR OVER

Name of Cardholder: ......

Amount: ......

Credit Card Number: ......

Exp Date: ......

Issue Number: ......

3 Digit Security Code: ......

Or please call 01628 897500 to give card details over the phone.

INTERNET BANK TRANSFER

Or you can pay by internet bank transfer:

Account Name: England HockeyAccount Number: 33371719

Sort Code: 20-40-71Bank: Barclays Bank

PAYMENT DATE:

CHEQUE

Or you can pay by cheque. Please put your name and reference number on the back of the cheque and post to the following address:

Jackie Bridger, England Hockey (EH), Bisham Abbey National Sports Centre, Marlow, Buckinghamshire, SL7 1RR

DATE CHEQUE POSTED:

*Mandatory information.

Core Information*
First name / Known as
Surname
Gender
(highlight as appropriate) / Male Female / Date of Birth dd/mm/yy
Full Postal Address including postcode / Email
Home Phone:
Mobile:
Work phone:
TERM TIME Address (if appropriate) / (only include if you require correspondence sent
to this address prior to the course)

Additional Personal Details

Emergency Contact Details * / Name:
Relationship:
Contact No.
Do you have any special requirements your tutor needs to be aware of during the course? *
please tick if you hold any of the following hockey qualifications:
(highlight as appropriate) / EH Level 1 Coaching Qualification 
EH Proud to Coach 
EH Level 2 Coaching Qualification 
EH Level 3 Coaching Qualification 
EH Level 4 Coaching Qualification 
EH GK Bronze Award 
EH GK Silver Award 
Please provide information on any other relevant awards held, e.g. Teacher/other sport coaching awards/assessing qualification/tutoring qualification
Playing history
How many hours a week do you currently spend coaching?
(highlight as appropriate) / Not currently active 
1-2 hours a week 
2-5 hours a week 
5-10 hours a week 
More than 10 hours a week 
which of the following levels do you currently coach?
(highlight as appropriate) / Ages 5-12 within a school 
Ages 12-18 within a school 
Ages 5-12 within a club 
Ages 12-18 within a club 
Club Coach with adult teams 
Back2Hockey 
which club(s)/school(s)/institute do you currently coach at?
which teams are you involved with?
Are you involved within the development pathway e.g jdc/jac/jrpc?
do you coach any other sports?
please provide any other relevant information on your coaching experience

England Hockey Equality Monitoring Form

England Hockey works hard and is committed to ensuring that everyone involved within hockey is not discriminated against. The information you give us helps us to provide fair and equal opportunities in hockey, it also helps us to deliver in a way that reflects our community and progress towards identifying any barriers to participation within hockey. This information will be used for monitoring only and not for any other purpose. It is strictly confidential and any data we hold will be stored separately from any data that could identify you personally. You are not obliged to answer all the questions but the more information you supply, the more effective our monitoring will be.

To make this possible we would be grateful if you could complete the following form.

  1. Disability
Do you have a long term illness, health problem or impairment that limits your daily activities?
 Yes /  No /  Prefer not to say
If Yes; which of the following best describes how your impairment or illness affects you?
Please select all that apply
 Hearing (deafness or hard of hearing)
 Vision (blindness or visual impairment)
 Social or behavioural issues, for example, due to neurological diverse conditions such as Autism, Attention Deficit or Aspergers’ Syndrome
 Mental Heath Problems
 Don’t know
 Prefer not to say /  Learning Disability (Learning or concentrating or remembering)
 Physical (wheelchair user, mobility issues, amputee, dwarfism)
 Other Disability(including Stamina or breathing difficulty, difficulty speaking or making yourself understood, dexterity difficulties, long term pain)
  1. EthnicityPlease tick the box that best describes your ethnic group

Asian or Asian British / Black or Black British
 Bangladeshi
 Indian
 Pakistani
 Other /  African
 British
 Caribbean
 Other
Mixed or Multiple Ethnic groups / White
 White & Black Caribbean
 White & Black African
 White & Asian
 Other /  British
 Irish
 Gypsy/Traveller
 Other
Chinese or Other Ethnic Group /  Prefer not to say
 Chinese
 Any other ethnic background
  1. Religion Please tick as appropriate

 Christian
 Muslim
 Jewish /  Hindu
 Buddhist
 Sikh /  No religion
 Other religion
 Prefer not to say
  1. Sex Please tick one box

 Female /  Male /  Prefer not to say

Thank you for completing this form and helping us make hockey a fair and equitable sport.

If you would like help to complete this form or a copy of this form in another format, such as larger print, Braille, audio or in a different language, please contact England Hockey on 01628 897500 or .

Declaration *

  • The data on this form is true and correct to the best of my knowledge.
  • I agree to abide by the England Hockey Regulations which includes the Code of Ethics and Behaviour
  • I have read and agree to the Conditions of Booking on page 5.

Signed: / Dated:

Conditions of Booking

  1. Bookings can only be confirmed following the completion of an application form and once payment has been processed.
  1. No organisation or individual attending the course may take photographic or video footage without prior written consent from England Hockey
  1. All bookings are accepted on the understanding that any regulations made by the venue for the safety or convenience of those using facilities will be strictly observed.
  1. All learners agree to abide by the General Rules and Conditions for the use of the venue.
  1. All learners take part at their own risk.
  1. No refunds will be given for learners who decide the course is not the correct one for them.
  1. England Hockey reserves the right to alter the course fee. Whenever possible prior notification will be given, but charges will always be based on fees current at the time of the event or course.
  1. All learners agree to the sharing of their contact details with other coaches in attendance on the workshop, in additional to third parties to assist in future Coach Development

Learner Cancellation and Transfer Policy

Please note the following cancellation policy applies should you cancel your place on this workshop:

  • Cancelled less than 21 days prior to the start of the workshop – no refund will be given except in exceptional circumstances. Evidence may be required.
  • Cancelled more than 21 days prior to the start of the workshop – a full refund will be issued less a £10.00 admin fee.
  • It is not possible to transfer a candidate onto an alternative workshop, a separate booking must be made and the cancellation policy will apply as above.

Please note: England Hockey reserves the right to cancel the workshop if it is not financially viable.In the event of cancellation by EH, an alternative option will be offered or a full refund will be issued. EH accepts no liability for any other expenditure incurred or loss sustained to the learner.

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