Volunteer Assistant Coach or TrainerApplication
Assistant Coach- a minimum of HTCP Development 1, Speak Out/Respect in Sport and a Police Clearance for the vulnerable sector
Trainers- a minimum of HTCP Level II, Speak Out/Respect in Sport and a Police Clearance for the vulnerable sector
Name: ______
Address: ______
Phone (H): ______Phone (W):______E-mail:______
Please clearly indicate your 1st, 2nd, and 3rd choices for teams
______Brockville Braves / ______Carleton Place Canadians / ______Cornwall Colts______Cumberland Grads / ______Gloucester Rangers / _____Hawkesbury Hawks
______Kanata Lasers / ______Kemptville 73’s / ______Nepean Raiders
______Ottawa Senators / ______Pembroke Lumber Kings / ______Smiths Falls Bears
Technical/Practical Certification
Speak Out/Respect in Sport – Year Attained: ______
Old NCCP -- New NCCP
Coach – Year Attained: ______/ Development 1 Year: ____Intermediate – Year Attained: ______/ Development 2 Year: ______
Advanced I – Year Attained: ______/ High Performance 1 Year: ______
Advanced II – Year Attained: ______/ High Performance 2 Year: ______
Old NCCP - Theory
Level I – Year Attained: ______Level II – Year Attained: ______Level III – Year Attained: ______
Trainer :
Level II – Year Attained: ______Level III – Year Attained: ______
Previous Hockey Coaching Experience:
Position ______Level ______Organization ______
Position ______Level ______Organization ______
Position ______Level ______Organization ______
Position ______Level ______Organization ______
Other Sports Coaching Experience:
Position ______Level ______Organization ______
Position ______Level ______Organization ______
Position ______Level ______Organization ______
Suspensions:
Has any minor or adult sport association ever suspended you as a coach or volunteer?
YES___NO___
IF YES, PLEASE PROVIDE DETAILS.
______
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References: (Please list 3 references i.e. Volunteer Executives, Coaches, Etc).
Name: ______
Address: ______
City: ______Province: ______Postal Code:______
Phone (Residence): ______Phone (Business): ______
Name: ______
Address: ______
City: ______Province: ______Postal Code: ______
Phone (Residence): ______Phone (Business): ______
Name: ______
Address: ______
City: ______Province: ______Postal Code: ______
Phone (Residence): ______Phone (Business): ______
Briefly, why you would like to assistant coach or Trainer; and what your season’s intentions would be:
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Screening
The HEO Midget AAA League is committed to reducing harassment, abuse and bullying in our programs. As a priority we are screening volunteers and staff to ensure the highest quality of personnel to support our programs and create a friendly and welcoming environment for our participants.
Please be advised that your position will require a criminal records check for vulnerable persons.
Do you wish to disclose any previous record(s) of offences?
No
Official Charge Date of Conviction ______
Disclosure or discovery of a previous record of offence may be considered in the person’s application for position within the HEO Midget AAA League. Based on the circumstances of the record, a person may be excluded from participation within the HEO Midget AAA League.
I hereby acknowledge that the information provided above is accurate to the best of my knowledge. I hereby consent to an Executive member of ODMHA and HEO Midget AAA Leaguecontacting the references listed above.
Signature______Date ______
Personal information used, disclosed, secured or retained by the HEO Midget AAA Leaguewill be held solely for the purposes for which we collected it and in accordance with the National Privacy principles contained in the Personal Information Protection and Electronic Documents Act(PIPEDA) as well as HEO’s own Privacy Policy.
DEADLINE FOR APPLICATION SUBMISSON: MAY 22, 2015
Please return application to Else Godo (ODMHA Director at Large) via scanned email to:
*Only the applicants where team’s express interest will be contacted.
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