LMHA Coaching Application

LMHA Coaching Application
Name*

First NameLast Name
Phone Number*

Area CodePhone Number
E-mail*
Coaching Information
CEP #
What Coaching Position:

Head CoachAssistant CoachPractice Coach
Levels Coached:

Learn to Skate6U/Mini-Mites8U/MitesSquirtsPeeweesBantamsMidgets
Level Applying to Coach:

Learn to Skate6U/Mini-Mites8U/MitesSquirtsPeeweesBantamsMidgetsArctics Girls Hockey
Date of Last Background Check

MonthDayYear
Highest Level of Coaching Certification Completed:
Date Issued:

MonthDayYear
Insurance Information
Insurance Carrier*
Group ID*
Subscriber ID*
Emergency Contact*

First NameLast Name
Emergency Contact*

Area CodePhone Number
Preferred Hospital*

Massena Memorial HospitalCanton-Potsdam Hospital
Disclaimer!

If you are selected to coach, you must complete following prior to stepping onto the ice for the season:

-Register with USA Hockey- Go Here To Register!

-Complete Safe Sport

-Complete proper level USA Hockey coaching clinic

-Complete all USA Hockey modules
Additional Information (about you, details about past coaching experience)
Should be Empty:

Coaching Information