English - Coaches Association of Ontario

Fundamental Movement Skills ONTARIO MULTI-SPORT LEARNING
FACILITATOR – APPLICATION FORM
Name ________________________________________________
Nom
Date of Birth
Date de naissance
Address ______________________________________________
Adresse
Gender
Sexe
City____________________________
Ville
Citizenship Status__________________
Citoyenneté
Postal Code ______________
Code Postal
Province_____________
_____________
D/J M Y/A
_______________________
Telephone (day)__________________ Telephone (eve)____________________
Téléphone (de journée)
Téléphone (de soir)
Languages spoken _____________________________
Langues parlées
E-Mail
________________________________
Adresse électronique
Sport___________________________________________
Second Sport : ___________________________
NCCP CC#
No de CC du PNCE
WORKSHOP PREFERENCES
THE CAO WORKS WITH DIFFERENT TYPES OF AFFILIATE LOCAL PARTNERS. PLEASE INDICATE YOUR INTEREST IN
FACILITATING WORKSHOPS IN THE FOLLOWING: (You may choose one or multiple.)
____ Community Centres - Municipalities
____ Community Sports Councils
____ Highschools
____ Universities or Community Colleges
____ Provincial Sport Organizations
____ Aboriginal Communities
PLEASE INDICATE IF YOU ARE CURRENTLY AFFILIATED (e.g. Faculty) WITH ANY EDUCATION INSITUTION OR
MUNICIPALITY.
____ YES
____ NO
WHERE WILL YOU FACILITATE FMS? _____________________________________________________________
GEOGRAPHIC AREAS WILLING TO TRAVEL
____ Eastern Ontario
____ Northwestern Ontario
____ Northeastern Ontario
____ Central
____ Southwestern Ontario
GEOGRAPHIC AREA OF PRIMARY INTEREST
____ Eastern Ontario
____ Northwestern Ontario
____ Northeastern Ontario
____ Central
____ Southwestern Ontario
SPECIAL INTERESTS / FOCUS
____ Youth Coaches (Age 16-18)
____ Aboriginal Communities
____ Women Coaches
____ Paralympics (Coaching Athletes with a Disability)
EDUCATION BACKGROUND
Education/Études
Post-Secondary Education/Études postsecondaires
Period of study/Période d’études
From/Du
To/Au
Institution/Établissement
Name/Nom
Credit Received
Crédit obtenu
In addition to attaching your NCCP Transcript obtained from the CAC database www.coach.ca please list additional
information regarding the following:
Advanced Coach Education/Formation avancée en entraînement
From/Du
To/Au
Institution / Program Description
□
Year/Année
WAS A PRESENTER AT COACHING CONFERENCES, CLINICS & WORKSHOPS
_____________________________________________________
Name of event & location
__________________
Year
_____________________________________________________
Name of event & location
__________________
Year
_____________________________________________________
Name of event & location
__________________
Year
Please list and briefly describe other educational roles / opportunities you have performed. (e.g. Technical course
Learning Facilitator for NCCP, teacher, evaluator, etc.)
In your view, what 3 or 4 topics do you think Ontario coaches should be invited to discuss when they get together in a
multi-sport group?
Please attach any additional information or statements about your background that you feel would contribute to becoming a
Learning Facilitator for the multi-sport modules offered within NCCP.
Please check all that apply and indicate the number of years or timeframe on the right.
Coaching Roles
POSITION
Assistant Coach
Program Coach
Head Coach
Mentor Coach
Age of Athletes Coached
YEAR(S)
POSITION
Youth under age 8
Ages 8-12
Ages 13-18
Ages 19-22
Adults
Seniors (Age 55+)
Sport(s) Coached
Program Level Coached
POSITION
Elementary or Highschool
College or University
Club or Community League
Provincial Team
National Team
YEAR(S)
Coaching Opportunities / Experience
POSITION
National team selection camp
Regional Championships (sport-specific)
Provincial Championships (sport-specific)
Canadian Championships (sport-specific)
National Team
International events (sport-specific)
World Championships (sport-specific)
Provincial Multi-sport Games
Canada Games
Commonwealth Games
Pan-Am Games / Para Pan-Am Games
Olympic Games / Paralympic Games
YEAR(S)
YEAR(S)
DECLARATION
I hereby certify that the information I have provided with this application is true.
Signature of Applicant
Please send your application information to:
Coaches Association of Ontario
Suite 108 – 3 Concorde Gate
Toronto, ON M3C 3N7
FAX 416-426-7331 or
Email: [email protected]
Your application must include the following. Forms are available on CAO website.
□
Cover Letter
□
Completed APPLICATION FORM
□
Signed NCCP Code of Conduct
□
Transcript of your NCCP Certification Status
□
References
All applications will be acknowledged upon receipt.