Head Coach Registration (Raiders Hockey Club)

Team

Please select the team you are associated with and your position on that team staff.

21-22 Raiders Team^*

Example: U12

Team Position^*

Personal

Please enter your name, date of birth and complete address.

First Name^*

The name entered here must be the same as the name entered when registering for Certification Clinics

Last Name^*

Date of Birth^*

mm/dd/yyyy Type the date in using this format or select from the calendar. Birthdate is required when registering a coach to a roster in the Hockey Canada Registry

Address^*

City^*

City Only, Please DO NOT include Province

Postal Code^*

Communication

Please list the email addresses and phone numbers you wish to share. We must have 1 email address and 1 phone number for communication purposes. You control what we make public for privacy reasons so please indicate which information, if any, that you would like to display in your team profile. A COPY OF THIS FORM WILL BE SENT TO PRIMARY EMAIL 1 AS CONFIRMATION OF YOUR SUBMISSION

Email Address^*

Example: yo[email protected]. Your submission will be sent to this address.

Home Phone

Example: ###-###-####

Cell Phone

Example: ###-###-####

Certification

Please insert your current level of certification in each category if applicable. All team personnel must have PRS Certification.

Coach Certification

Trainers Certification

Respect in Sport ^*

Gender Identity and Sensitivity Modules Completed^*

YesNo

Police Check

Valid Police Checks must have an issue date after January 1, 2017

Status

Date Issued

Please scan or take a picture of both the front and back of Police Check and upload here.

Allowed extensions: .jpeg, .jpg, .png, gif, .pdf.
Maximum # Files: 4. Maximum File Size: 4MB.

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