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2017-2018 NCCP High Performance 1

Personal Information

First Name *  
Last Name *  
Date of Birth *    
Format: yyyy-mm-dd

Address Information

Street Address *  
City/Town *  
Country *
Province *    
Postal Code *  

Contact Information

Phone Number *    
Format: 555-555-5555
Email *    
MHA *  
Role*  
T-Shirt Size*  

Team Experience (Team, Category)

Projected 2017-2018 Team
2016-2017 Team
2015-2016 Team
2014-2015 Team
NCCP #
Certification Level
HCR #
Year Attained

Medical Information

BC Care Card Number *  
Family Doctor *  
Doctor Phone *    
Format: 555-555-5555
Medical Insurance Number
 
Group Number
 
Certificate Number
 

Hospitalized in the last year?
 
Presently injured?
 
Injuries requiring medical attention?
 
Wears dental appliance?
 
Ill longer than one week in the past year?
 
Wears contact lenses?
 
Allergies to medication, etc?
 
Asthmatic?
 
Trouble breathing during exercise?
 
Diabetic?
 
Fainting during exercise?
 
Epileptic?
 
Difficulty hearing?
 
Heart Condition?
 
Interfering health problems?
 
Learning disability?
 
Medic alert bracelet?
 
Wears glasses?
 
History of concussions?
 
Taking medications?
 
Surgery in the past year?
 
If you selected YES to any of the above medical conditions that may affect your ability to fully participate in the camp, please specify below.

Seminar Fee: $1,750.00
GST: $87.50
Total: $1,837.50

Application Deadline: June 25, 2017. Please note: registration fee includes accommodation and meals. The following refund policy applies to cancellations:
50% refund up until 15 days prior to the scheduled seminar.
NO REFUND within the 15 days prior to the start of the seminar.


Coaching/Education Resume:  

MHA Letter of Reference:  


All applications will be reviewed the by Coach Committee Review Team. Successful applicants will be contacted by June 1, 2017 and payments will be taken at that time.


ABOUT US
BC Hockey is a non-profit organization and member branch of Hockey Canada in charge of governing amateur hockey at all levels in British Columbia and the Yukon Territory.

Approximately 150 minor hockey associations, 55,000 players, 4,500 referees, 20,000 official volunteers and countless others make our great game possible here in Pacific Canada.

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