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Port Colborne Minor Hockey Association Coach and Convenors Application Form 2010 – 2011 Season
Name:
(Given Name)
(Middle)
(Surname)
Address:
Postal Code:
Phone
(Home)
(Work)
(Cell)
Fax #:
Email address:
Best time to reach me:
Preferred Assignment
COACHINGDIVISION CONVENOR
Please indicate your preferred division: 1(first choice) and 2 (your second choice).
REP
House League
TYKE
NOVICE
ATOM
PEEWEE
BANTAM
MIDGET
Certification / Training *NCCP (National Coaching Certification Program)
Year Completed
Location/ #
Speak Out
Trainer certification
CHIP
Coach developmental level or Coach recreational stream
Intermediate or advance level
NCCP Theory 1
NCCP Theory 2
CHSP
Checking Clinic
Coaching Association of Canada # :
* All coaches must have the minimum Coach level certification required by OMHA Manual of Operations and have completed a Preventive Services course.Coaches not having the minimum will be required to obtain proper certification prior to the start of the season. Coaches applying for the first time may be required to submit a Police Check prior to the start of the season.
Please list your coaching/convening experience: use a separate page if needed
Season (list the most recent first)
Organization
Age Group
Level(HL, Select, Rep)
Position
Have you ever been suspended due to your own misconduct on the bench? Or have you ever been removed from a coaching position in any other organization?
If you are applying for the first time or if it has been more than three years since you have coached with PCMHA, please provide three (3) references who would be able to comment on your experience, qualifications and skills related to this coaching/convenor application.
Name
E- mail Address
Phone Number(s)
1.
2.
3.
Please submit your application to your House League Convenor Dave Roy or to the travel team convenor Gord Lannan.
Also cc - Cherie Bellantyne our secretary when possible.
Thank you.
I have read and understand the Volunteer coaching policy and PCMHA code of conduct.
Signature of applicant: _____________________________________________________
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