Mid Fairfield CT Stars
2013-2014 Coach Application

1. Personal/contact Details:

Name: ______

Street Address: ______

City, State, Zip Code: ______

Home Phone: ______
Cell Phone: ______
E-Mail Address: ______

How were you referred to the Mid Fairfield CT Stars? ______

Are you interested in a Head or Assistant Coach position? ______

Do you have any children currently playing with the MF CT Stars? Yes  No 
If yes at what level? ______

2. Academic History:

High School Attended: ______Graduated? Yes  No 

College/University Attended: ______Graduated? Yes  No 
If graduated, degree and major: ______

3. Coaching Experience:

(Please start with most recent experience)

Dates (mm/yy-mm/yy) / Organization / Level/age group / Head/Co/Assistant?

3a. Are you currently a USA Hockey certified coach? Yes  No 

If yes, at what level? ______USA Hockey CEP #: ______

4.Playing Experience:

(Please start with most recent experience)

Dates (mm/yy-mm/yy) / Team / Level / Position

5. Which level are you interested in coaching? Please circle no more than two:

Tier 1:U12U14U16U19

Tier 2*: U12U14U16U19

*Please note that the formation of Tier 2 teams will be based on tryout results.

6. Please briefly describe your coaching style and philosophy. Include objectives and goals that you typically set for yourself and the team (feel free to utilize the back of this application or additional paper to complete your response.

8. Background:

You may answer “no” to the following questions if the conviction or records thereof have been annulled, sealed, set aside, or purged, or if you have been pardoned pursuant to law.

An affirmative answer to any of the following questions does not automatically disqualify you from coaching at the Mid Fairfield CT Stars. Convictions of a crime will be considered only in relation to specific coaching duties or requirements.

Have you ever been convicted of a felony? Yes  No 

Have you been convicted of a misdemeanor (excluding a first conviction for drunkenness, simpleassault, speeding, minor traffic violations, affray or disturbance of the peace) within the past five (5) years? Yes  No 

If you have been convicted of a felony within the last five (5) years, please state whether you hadany prior misdemeanor convictions more than five (5) years ago. Yes  No 

Are there any misdemeanor and/or felony charges pending against you? Yes  No 

If Yes to any of the above questions, Please Explain: (At a minimum, please indicate the nature ofyour offense): ______

______

9. References:

Please provide the names and phone #’s of three people who can discuss your role as a coach or athlete. Individuals should not be related to you and do not live with you.

Name / Contact Phone # / Relationship to you
1)
2)
3)

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Applicant’s statement, authorization and release of liability
I certify that all the information given by me in this application is true and correct to the best of my knowledge. I understand that false or misleading statements made by me or consequential omissions of any kind in the application process, are sufficient cause for my not being accepted as a coach or for my dismissal, no matter when discovered.
I authorize the Mid Fairfield Youth Hockey Association to investigate all information contained in this application. The individuals named are authorized to give you any and all information regarding my work, character, fitness and qualifications, including opinions, that they may have about me.
In consideration of the evaluation of this application by the Mid Fairfield Youth Hockey Association, I HEREBY WAIVE, RELEASE AND DISCHARGE the Mid Fairfield Youth Hockey Association, all organizations and individuals and any other persons or entities from liability for all damages and losses of whatever kind or nature, except liability for willful intentions, acts, or punitive damages, that may result from compliance or attempts to comply with this authorization.
Signature: ______

Print Name: ______
Date: ______
Coaching selections are subject to the Mid Fairfield Youth Hockey Association Board approval. Please return applications to Carolyn Holt, Director of Girls Hockey, Fax # 203 227 4669 or e-mail to
DEADLINE TO SUBMIT APPLICATION IS March 15, 2013

MID FAIRFIELD YOUTH HOCKEY ASSOCIATION

DISCLOSURE STATEMENT

MID FAIRFIELD YOUTH HOCKEY ASSOCIATION will not authorize any volunteer or employee who has routine access to children (anyone under the age of majority), who refuses to consent to be screened by Mid Fairfield Youth Hockey Association prior to being issued acceptance/approval for routine access to the children who take part in Mid Fairfield Youth Hockey Association program.

Volunteer Disclosure Agreement

(Please Print)

______Last Name First Name Middle Initial

______Address City State Zip Code

______Social Security Number REQUIRED ______Date of Birth REQUIRED Home Phone Work Phone

______Previous Address(s) if located in another state within the past 10 years

I have read and understand that a person maybe disqualified and prohibited from serving as an employee or volunteer of Mid Fairfield Youth Hockey Association, if among other things, the person has:

1. Been convicted (including crimes the record of which has been expunged and pleas of "'no contest"") of a crime of child abuse, sexual abuse of a minor, physical abuse, causing a child's death, neglect of a child, murder, manslaughter, felony assault or any assault against a minor, kidnapping, arson, criminal sexual conduct, prostitution related crimes, or controlled substance crimes;

2. Been adjudged liable for civil penalties or damage involving sexual or physical abuse of children;

3. Been subject to any court order involving any sexual or physical abuse of a minor, including, but not limited to domestic order or protection;

4. Had their parental rights terminated; 5. Has history with another organization (volunteer, employment, etc.) of complaints of sexual or physical abuse of minors;

6. Resigned, been terminated or been asked to resign from a position, whether paid or un-paid, due to a complaint(s) of sexual or physical abuse of minors;

7. Has a history of other behavior that indicates they may be a danger to children in Connecticut Hockey Conference and/or its members’ programs;

Do any of the above apply to you?YES_____NO ______If YES, please describe______

______

I certify that all information given by me in this application is true and correct to the best of my knowledge. I understand that false or misleading statements made by me or consequential omissions of any kind in the application process are significant cause for my not being accepted as a volunteer/employee or for my dismissal no matter when discovered. I authorize Mid Fairfield Youth Hockey Association to investigate all information contained in this application, including, but not limited to a criminal records investigation. The employers, organizations, and individuals name are authorized to give you any and all information regarding my employment, volunteering, character, fitness and qualifications (including opinions) that they have about me.

In consideration of the evaluation of this application by Mid Fairfield Youth Hockey Association. I HEREBY WAIVE, RELEASE AND DISCHARGE Mid Fairfield Youth Hockey Association, all employees, organizations and individuals, and any other persons or entities from Liability for damages and losses of whatever kind or nature, except liability for willful or intentional acts or punitive damages, that may result from compliance or attempts to comply with this authorization.

Signature______

Date______
Coaching selections are subject to the Mid Fairfield Youth Hockey Association Board of Governors approval. Please return applications to Carolyn Holt, fax 203-227-4669 or e-mail .

DEADLINE TO SUBMIT APPLICATION IS March 1, 2012