Your Name *

Your Email *

Will you have a child playing in the division you have applied for? *

Are you applying to Head Coach, Assistant Coach or Manage *

Age Group you are applying to coach? *

If you are not selected to coach a "Gold" team would you be interested in coaching a "Silver" or house league team *

If you are not selected as a Head Coach would you be willing to be an assistant coach? *

Please list previous coaching experience. (Year, Team, Age Group, Position, Sport) *

Coaching Clinics/Courses Obtained *

Please provide any other relevant hockey background (player evaluation, hockey school, camps, provincial or national experiences) *

Briefly describe your coaching philosophy as well as your season objectives *

I agree to follow the Bylaws, Regulations and Policies as set out by Portage Minor Hockey, Hockey Manitoba and Hockey Canada. *

What is your Date of Birth *

Phone Number *

Current physical Address *

Please verify that you are a human.