HEO MIDGET AAA
Volunteer Assistant Coach or Trainer Application
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: _______
HEO Midget AAA
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HEO MIDGET AAA
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.
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
REFERENCES: (PLEASE LIST 3 REFERENCES I.E. VOLUNTEER EXECUTIVES, COACHES, ETC).
Name: ______________________________________________________________________
Address: ____________________________________________________________________
City: ___________________________ Province: _______ Postal Code:_________
Phone (Residence): __________________ Phone (Business): ________________________
HEO Midget AAA
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HEO MIDGET AAA
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:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
HEO Midget AAA
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HEO MIDGET AAA
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 League contacting the
references listed above.
Signature_____________________________ Date _________________________________________
Personal information used, disclosed, secured or retained by the HEO Midget AAA League will 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:
[email protected]
*Only the applicants where team’s express interest will be contacted.
HEO Midget AAA
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