NAME        __________________________________________________

ADDRESS ________________________________________________________________________________________________

HOME       _________________________________  CELL ________________________ BUSINESS_______________________

TEAM SELECTION 

REP___________     LOCAL LEAGUE______________ SELECT______________

TYKE_____  NOVICE______ATOM______ PEEWEE ________ BANTAM _______ MIDGET_______  JUVENILE _______ 

IF THESE CHOICES ARE NOT AVAILABLE WOULD YOU CONSIDER ANOTHER POSITION   YES_____   NO______

____________________________________________________________________________________________________________________

HOCKEY COACHESCERTIFICATION PROGRAM (HCCP)

 (PLEASE  FILL OUT ALL APPLICABLE AREAS AND ATTACH COPIES OF CERTIFICATES)

    COACHING LEVEL    ________________________________________________    YEAR   ATTAINED __________________

    PRS (SPEAK OUT MANDITORY)   ___________________________________

ARE THERE ANY OTHER CERTIFICATES YOU HOLD?      (CPR, HTCP,FIRST AID )

_________________________________________________________________________________

DO YOU PRESENTLY HAVE A CHILD PLAYING IN MIDLAND MINOR HOCKEY ASSOCIATION?    YES___ NO ____

 NAME ________________________ LEVEL ________________________

HAVE YOU COACHED IN MIDLAND BEFORE?  _____________________________________________________________

PLEASE NOTE:

ALL APPLICANTS FOR COACH POSITIONS WILL BE REQUIRED TO COMPLETE A POLICE RECORD CHECK

COACHING PROFILE

Please attach your personal profile, reflecting your coaching skills and experiences, coaching philosophy, long and short term goals and any other related information not detailed in this application. Any additional information provided pertaining to the following would be appreciated

- Anticipated roles of team officials (assistants, managers and trainers)

- Team initiatives, objectives and goals

REFERENCES        (PLEASE LIST THREE HOCKEY RELATED)

                NAME        ______________________________________________

               ADDRESS ______________________________________________

                TOWN       ____________________POSTAL CODE_____________

         PHONE (RES) ____________________(BUS)_____________________

              NAME        ______________________________________________

              ADDRESS ______________________________________________

              TOWN       ____________________POSTAL CODE_____________

       PHONE (RES) ____________________(BUS)_____________________

              NAME        ______________________________________________

              ADDRESS ______________________________________________

              TOWN       ____________________POSTAL CODE_____________

       PHONE (RES) ____________________(BUS)_____________________

_________________________________________________________________________________________________

AUTHORIZATION FOR COLLECTION OF PERSONAL INFORMATION

I ,________________________________, authorize midland minor hockey to collect personal information appropriate to the position applied for concerning my academic background,  employment history and verify the character references I have supplied.

I understand that the information obtained will be confidential but may be shared with relevant organizations in order to obtain an appropriate volunteer position

_____________________________________             _____________________

            SIGNATURE                                                     DATE/MONTH /YEAR