The Australian Sports Commission, through its Active After-school Communities Program, will be conducting a number of training programs in the Barwon Region designed to train coaches to deliver structured physical activity programs to primary school aged children. In particular, it is designed to help AASC Community coaches understand the basics of:

 

• What motivates and engages children in physical activity, and
• The need to develop well structured physical activity session 

Copy and paste the following into a MS Word document and return to Alison Kooloos at: alison.kooloos@ausport.gov.au

 

Community Coach Training Enrolment Form

 

 

Course Date :______________________ Course Venue:___________________________

 

PERSONAL DETAILS

 

 

 

 

FIRST NAME: __________________________     LAST NAME:______________________________

 

DATE OF BIRTH: __________________________   GENDER (Please circle)               M / F

 

TELEPHONE: (W)______________________ (H) ____________________________

 

TELEPHONE: (M) _______________________________ FAX: __________________

 

EMAIL ADDRESS: _________________________________________________

 

POSTAL ADDRESS: ___________________________________________________

 

ACTUAL ADDRESS: ___________________________________________________

 

TOWN/SUBURB:_______________________ POSTCODE: ____________________

 

OPTIONAL

 

 

 

 

Are you of Aboriginal or Torres Strait Islander (TSI) origin?  

No □                                     ABORIGINAL □                                        tsi □

 

Do you have a significant disability or long term medical condition?   Yes / No

 

If yes, what is the nature of your disability?____________________________

 

___________________________________________________________________________

 

ARE YOU FROM A NON-ENGLISH SPEAKING BACKGROUND (NESB)?         Yes / No

 

If yes, please specify:______________________________________________ ____

 

WHICH ONE OF THE FOLLOWING APPLIES TO YOU?

 

 

 

 

 

ARE YOU:

□       An internal deliverer from a AASC school or OSHCS (i.e. employee or enrolled student of a AASC School or OSHCS)

 

□       Representing an Organisation (e.g. sporting club or local council)

 

□       An individual deliverer whether paid or volunteer, not representing an organisation

 

If representing an organisation or School/OSHCS, please list the organisation name:

 

                                                                                                                                            

 

Tick which of the following applies to you:

 

□    NSO, SSO, Regional Sporting body	□    Community member
□    Student	□    Private Provider
□    Local Club Member	□    Local Government
□    Other (please Specify) ___________________________________________

 

Have you completed any of the following qualifications (please attach evidence of completion):

 

□    Teaching qualifications or currently in 4th year (primary or secondary)

□    NCAS Beginning Coaching General Principles (or NCAS entry level coaching accreditation)

□    Certificate III in Childcare or above

 

 

PERSON TO CONTACT IN CASE OF EMERGENCY:

 

NAME: ____________________________________ PHONE:_________________________

 

The course may involve physical activities, some of which may require a reasonable level of fitness. Are there any known reasons: illness, disability, impairment or otherwise, which may impact, limit or restrict your participation in the course?

 

□   NO                 

□    YES    If ‘Yes’ please specify:

__________________________________________________________________

 

__________________________________________________________________

 

 

 

I declare the above information is true and correct. I authorise The Australian Sports Commission personnel to obtain medical assistance that they deem necessary should any medical problem or accident occur, and I agree to pay all medical expenses incurred on my behalf.

 

I agree to release the ASC from any liability to me for any injury or illness that I may suffer, and for any loss or damage to property in connection with the course, except where that liability arises as a result of negligence of the ASC.

 

The ASC collects personal information in the course of administering the AASC and this enrolment process. In order to administer the AASC, the ASC may disclose the personal details provided on this form to schools/OSHCS who are seeking to engage a person to deliver structured physical activities.

 

SIGNATURE: ____________________________________ DATE: ____________________

 

UNDER 18 (PARENT OR LEGAL GUARDIAN TO COMPLETE)

 

As the parent/legal guardian of ________________________________ ________________ I give consent to his/her participation in the Australian Sports Commission Community Coach Training for which he/she has enrolled and agree to the release and acceptance information stated above.

 

NAME:____________________________________ _____________________________

 

SIGNATURE:______________________________________ DATE: _______________________