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   Last Name (required)    First Name (required)

   Address     
                                    Postal Code

  Home Phone    Work Phone    Other Phone   

  E-mail (Required)

  REQUIRED:  Alberta Personal Health Card (APHC) Number:  

  DATE OF BIRTH (Required) (DAY / MONTH / YEAR)

  Are you certified in First Aid?    Yes   No                 Certification level 

  (If Yes) Name of first aid course:

  Have you completed the Canadian Hockey Association Safety Program course?     Yes    No

  Have you completed the Canadian Hockey Association Speak Out course?               Yes    No

  Expected Team Official position(s) in current hockey season (Head Coach, Assistant, Manager, Trainer - indicate all that apply)
  

  Expected Team Category(s) in current hockey season   i.e., Pre-Novice, Novice, Atom, PeeWee, Bantam - indicate all that apply)
    

  Coach Certification Level        Certification Number (if known)

  How many years have you been involved in hockey in the following capacities:

  Head Coach      Assistant Coach        Manager            Trainer

Previous Hockey Experience (3 most recent seasons)

   select Initiation Pre Novice Novice Atom PeeWee Bantam Midget Junior Other Coach Asst Coach Manager Trainer Other    

   select Initiation Pre Novice Novice Atom PeeWee Bantam Midget Junior Other Coach Asst Coach Manager Trainer Other    

   select Initiation Pre Novice Novice Atom PeeWee Bantam Midget Junior Other Coach Asst Coach Manager Trainer Other    

  NEW VOLUNTEERS ONLY - names and phone numbers of three volunteers or personal references who are not family members:

                                  Last Name                                                   First Name                                                 Phone

yes no I hereby give permission to Confederation Hockey Club to solicit all references in connection with my application for the volunteer position(s) indicated in this registration form.   A copy of this authorization shall be as valid as the original.  I hereby certify that all information included in the application form is true and complete.  I understand that an incomplete application will not be considered, and that providing false information is grounds for immediate disqualification from the application process, or immediate dismissal if the falsehood is discovered after placement.  Completion of this application form does not guarantee a team official position.  I further authorize Confederation Hockey Club with the authority to verify all statements herein and release them and all others from liability in connection with same.