PSAHA Coaching Application

Puget Sound Amateur Hockey Association
1918 Stewart St
Tacoma, WA 98421
(253) 830-7598
(253) 276-0081

Application for Coaching Position

Date:
Date of Birth: Month: Day: Year:
Name: Last: First: Middle:
Alias / Maiden Name:

Required for WSP purposes only Sex: Male: Female: Race:

Address:
City:    State:     Zip:
Driver's License Number:     Issuing State:

Gender Male: Female:

Citizenship:
E-Mail: Home Phone: Work/Cell Phone:
Fax:

Position Desired Head Coach: Assistant Coach: Manager:

Level Desired Tier 2: B: Recreational:

Division Mite & Under: Squirt: PeeWee: Bantam: Midget:

Second Choice: Desired Assistant Coach:1) 2) 3)

Do you have children playing in PSAHA? Yes: No:

If yes, Childs Name and level:    Child #1
                                                 Child #2
                                                 Child #3
                                                 Child #4

USA Hockey Coaching Level None: Initiation: Associate: Intermediate: Advanced:

CEP #: Year:

Previous coaching and hockey experience, including other sports:

Please discuss your coaching philosophy and reasons for wanting to coach youth hockey:

I certify that the above information is true to the best of my knowledge and I agree to follow the rules, regulations, and guidelines of USA Hockey, PNAHA, and Puget Sound Amateur Hockey Association.
I agree to exhibit good sportsmanship, guidance, fair play and accept the responsibilities entrusted to me by USA Hockey, PNAHA, and PSAHA.
I agree to submit to any background checks as required by USA Hockey, PNAHA, and PSAHA.
I agree to take any and all new refresher courses provided by USA Hockey, PNAHA, and PSAHA.
Finally, I agree to follow the USA Hockey Coaching Ethics Code.

I Agree:

(signature will be required at a later date)

Washington State Patrol
Identification and Criminal History Section
PO Box 42633
Olympia, WA 98504-2633
(360) 705-5100
http://www.wa.gov/wsp/wsphome.htm

REQUEST FOR CONVICTION CRIMINAL HISTORY RECORD (RCW 10.97)

    INSTRUCTION:    PLEASE COMPLETE THIS FORM WHEN REQUESTING CONVICTION CRIMINAL HISTORY RECORD INFORMATION FROM THE WASHINGTON STATE PATROL IDENTIFICATION AND CRIMINAL HISTORY SECTION. MAIL REQUEST TO ADDRESS NOTED ABOVE WITH $10 MONEY ORDER, COMMERCIAL BUSINESS ACCOUNT CHECK or CASHIER CHECK, PAYABLE TO THE WASHINGTON STATE PATROL.

NOTE: The requested record information is furnished solely on the basis of name and/or description similarity with the subject of your inquiry. Positive identification or non-identification can only be effected upon receipt of fingerprints. Subject may be advised of inquiry.

A business or organization must prepare a disclosure statement to be signed by the applicant before a background check may be conducted.
    A business or organization shall require each applicant to disclose whether the applicant has been:

No Yes       (a)    Convicted of any crime against children
No Yes       (b)    Convicted of crimes relating to financial exploitation if the victim was a vulnerable adult
No Yes       (c)    Convicted of crimes related to drugs as defined in RCW 43.43.830
No Yes       (d)    Found in any dependency action under RCW 13.34.040 to have sexually assaulted or exploited any minor or to
                                        have physically abused any minor.
No Yes       (e)    Found by a court in a domestic relations proceeding under Title 26 RCW to have sexually abused or exploited
                                        any minor or to have physically abused any minor.
No Yes       (f)    Found in any disciplinary board final decision to have sexually or physically abused or exploited any minor or
                                       developmentally disabled person or to have abused or financially exploited any vulnerable adult.
No Yes       (g)    Found by a court in a protection proceeding under chapter 74.34 RCW, to have abused or financially exploited
                                        a vulnerable adult.