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2020 HSA Select Coaching Application
Please provide as much information as possible; attach resumes or other background information. Deadline is January 31, 2020. (Be sure to review Job Description before submitting Application.)
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* Indicates required question
LEGAL Name
*
Your answer
Nick Name
Your answer
Date of Birth
MM
/
DD
/
YYYY
Address - City - Zip Code
Your answer
Email address
*
Your answer
Cell Phone #
Your answer
Current Occupation and Employer
Your answer
Position Desired
*
Head Coach
Assistant Coach
Required
Gender & Age Group you are applying for
*
Boys
Girls
U-11 (2010)
U-12 (2009)
U-13 (2008)
U-14 (2007)
U-15 (2006)
U-16 (2005)
U-17 (2004)
U-19 (2003)
Required
Current USSF Coaching License
*
Grassroots 4v4
Grassroots 7v7
Grassroots 9v9
Grassroots 11v11
E License
D License
C License
B License
A License
NONE
Required
Date obtained license (most recent)
MM
/
DD
/
YYYY
Other Coaching License(s)
Your answer
Risk Management Application (RMA) number (log into your Affinity account to view)
Your answer
RMA Expiration Date
MM
/
DD
/
YYYY
Are you currently coaching?
*
Yes
No
If Yes, name of Association and Club
Your answer
Years of Coaching Experience
Your answer
How many teams do you plan to coach this upcoming season?
1
2
Clear selection
Are you certified to ref?
Yes
No
Clear selection
If yes, what is your grade?
Grassroots (formerly Grades 7, 8 & 9)
Advanced Grassroots
Regional (formerly Grades 5 & 6)
Clear selection
Coaching Experience: describe coaching positions, starting with the most recent. Include dates, gender, age, level of play (recreational or competitive), club/association, and your position (head coach, assistant coach, trainer). (You can send Coach Bio/Resume to
hsaselect@gmail.com
to meet this requirement.)
Your answer
Describe your soccer training and playing experience. (You can send Coach Bio/Resume to
hsaselect@gmail.com
to meet this requirement.)
Your answer
Please list all coaching clinics, seminars and classes attended. (You can send Coach Bio/Resume to
hsaselect@gmail.com
to meet this requirement.)
Your answer
List any special achievements or awards. (You can send Coach Bio/Resume to
hsaselect@gmail.com
to meet this requirement.)
Your answer
REFERENCES – list references (up to 3) who are willing to provide information on your coaching ability. List name and phone number.
Your answer
Have you ever been terminated from or been asked to resign your position with a youth organization?
*
Yes
No
If Yes, please explain.
Your answer
Have you ever been subject to disciplinary action, placed on probation or suspended by a youth organization because of disciplinary action?
*
Yes
No
If Yes, please explain.
Your answer
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