Personal Details

Name

Address

Email

Tel:   Home                              Work                                        Mobile

Club attached to – if any

Hockey Coaching Qualifications                                                 Date Taken

Hockey Non-certificated Skills Updates Attended

Coaching and Management Experience (School/Club/County/Regional/National/ Development)

Non-Hockey Training/Courses Attended                                    Date Taken

SCUK    Safeguarding Young People

SCUK    Equity in your Coaching

SCUK    Working with Disabled Sportspeople

Risk Assessment/Health and Safety Training

Other

CRB Check  Y/N     Through KHA    Y/N      Date            Cert. No.

First Aid Qualification/Date of Course/Agency

Sports Injury or Care of Athletes Training/Date of Course/Agency

Coaching Insurance Agency (i.e. England Hockey/SCUK)     Expiry Date

Other Information

I understand that my details will be used by KHA and listed in the KHA handbook.

Signed                                                                                          Date