Schomberg Minor Hockey Association

Name: ________________________________________________________________

Address: ________________________________________________________________

City: _____________________________ Province: _______ Postal Code: _________

Phone: (Res.) __________________________ (Bus.)______________________________

Fax__________________________________ E-mail _____________________________

1^st CHOICE: LEVEL__________________________ REP   LL

2^nd CHOICE: LEVEL__________________________ REP   LL

CHIP Certification Year Attained ___________ # _______________________

PRS Certification Year Attained ___________ # _______________________

Police Screening Year Attained ___________ (please attach copy, if expired please complete attached screening form and have certified before attaching)

Please list your coaching/training experience, include S.M.H.A and any other hockey associations as well as at least one reference from each association.

YEAR ASSOCIATION TEAM/LEVEL POSITION HELD

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(List three references; i.e. player 12 & over, parent, professional)

Name: _______________________________________________________________

Address: _______________________________________________________________

City: _____________________________ Postal Code: ___________________

Phone: Res: _________________________ Bus: __________________________

Name: _______________________________________________________________

Address: _______________________________________________________________

City: _____________________________ Postal Code: ___________________

Phone: Res: _________________________ Bus: __________________________

Name: _______________________________________________________________

Address: _______________________________________________________________

City: _____________________________ Postal Code: ___________________

Phone: Res: _________________________ Bus: __________________________

(attach separate sheets where necessary)

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I understand that completing a "Coaches Application" with the Schomberg Minor Hockey Association does not ultimately guarantee me a coach’s position within the S.M.H.A.

If selected as a coach, I agree to follow all OMHA, SMHA, and SRMHL rules and regulations including the "Harassment Policy" guidelines. Be advised of S.M.H.A Rules of Operation, Section "5.4" with regards to Local League team balancing and player movement. Schomberg Minor Hockey Association is a certified "OMHA Coaches Mentor Program" centre, therefore I also agree to participate in and adhere to the guidelines of the "OMHA Coaches Mentor Program".

I hereby certify that the above information to be true and correct.

Please complete the "Authorization for Collection of Personal Information" form attached.

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Applicant Signature Date

PLEASE MAIL COMPLETED APPLICATION TO:

SCHOMBERG MINOR HOCKEY ASSOCIATION

P.O. BOX 145

SCHOMBERG, ONTARIO

LOG 1T0

Attention: Secretary

Schomberg Minor Hockey Association

I, ______________________________________________, authorize Schomberg Minor Hockey Association to collect personal information appropriate to the position applied for by verifying the character references I have supplied.

I also understand that in order for my application to be considered, I must submit to a criminal reference check.

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

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Applicant Signature Date

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Witness Date

Email App to :

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