Shelburne County Minor Hockey Association

P.O. Box 513
Barrington Passage, NS
B0W 1G0
Coaching Application Form 2009 – 2010

Personal Information:

Name: _________________________________________ Email: _________________________________________

Primary Phone: _______________________________ Secondary Phone: ___________________________________

Address: ______________________________________________________________________________________

Coaching Qualifications:

CC Number: ______________________ NS Number: _________________________

National Coaching Certification Program

Initiation Program ~ (Date Attended)__________________
Coach – Level 1 ~ (Date Attended)__________________
Development Stream “A” ~ (Date Attended)__________________
Intermediate – Level 2 ~ (Date Attended)__________________
Advanced – Level 3 ~ (Date Attended)__________________

Other Qualifications:
First Aid – Level _____
CPR – Level _____
Speak Out
Hockey Safety Program

Previous Coaching Experience:

(Year)______(Association)________ (Division & Level)____________(Head Coach) (Assistant) (Trainer)

Requested Coaching Position:

Atom - (Male) (B) (A) (AA)
Pee Wee - (Male) (B) (A) (AA)
Bantam - (Male) (B) (A) (AA)
Midget - (Male) (B) (A) (AA)

If applicable, enter a second choice: __________________________________________

Please answer the following questions:

1. Have you ever been dismissed by any amateur sports association? Yes No

2. Have you ever been suspended while coaching an amateur sports team? Yes No

3. Have you ever been involved in a physical altercation with anyone before, during or after a game? Yes No

4. I agree to follow the Fair Play philosophy and the coaching policy set out by the SCMHA. Yes No

Additional Information:

All SCMHA coaches must have completed a “Child Abuse Registry Form” and “Police Check” in order to be eligible to coach. These forms must be completed before the coach’s interviews. SCMHA coaches from previous years who have completed these two forms in the past may not be required to do so for this season. However, ALL APPLICANTS are encouraged to have them completed.

Coaching applications are due no later than September 11, 2009. Any late applications will not be considered.

Please forward completed applications to:

Shelburne County Minor Hockey Association
P.O. Box 513
Barrington Passage, NS B0W 1G0

I ensure that the information provided on this application is accurate and truthful.

Signature: ________________________________________ Date: ___________________________________