Dope Coach Academy Application

Applicant Details:
Full Name*

First NameMiddle NameLast Name
Gender*

malefemale
Birth Date*

MonthDayYear
Country *
Do you have any prior knowledge of trauma-informed or brain-based coaching?*
School or Organization Name & Mascot
What Sport or Sports do you Coach?
Phone Number*
School or Organization Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail*
example@example.com
What other Coach, Trainer, Athlete, or Parent you think may also be interested in Trauma-Informed & Brain-Based Coaching?:*
Referral
Title*
ex. Coach, Trainer, Athlete, Parent
Phone number or Email Address of Referral (We’ll only send one introduction email. NO SPAM)*
The D.O.P.E. Program applying for:
Name of Course:*
How do you prefer to learn?:*

VirtualIn-PersonHybrid
Tuition Information:
Who is expected to pay for your course?*

YourselfSponsorApply for Scholarship
Name and address to which invoice is to be sent(if different from above)
Education:

Please give details of all Schools/Colleges/Universities attended.

Secondary/Further/Higher Education

Rows	Name of secondary School/College/University	Address	Dates Attended From(mm/yy)To(mm/yy)

Educational Qualifications

Certifications

What level do you Coach?*

Middle SchoolHigh SchoolRecreationalElite (Travel)Professional
Reference:

All applicants must provide one reference.The reference should be a coach, athlete, parent, or trainer that you have either played for, coached, or otherwise worked with in a sports setting.
Name of reference
Organization
Relationship to you
Email
Name of referee 2
Organization
Relationship to you
Email
Please tell us where you found out about this course
Support Requirements:

Please complete this section if you have any learning support/mobillity requirements.
Do you have a disability, injury, medical conditon or require learning support?

YesNo
If yes,please name and give brief details:
Date

daymonthyear
Should be Empty:

Applicant Details: