2024-2025 Coach Screening Disclosure Form

Personal Information

Question Title

* NAME:

First Name:

Middle Name:

Last Name:

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* Other Names You Have Used (i.e. Given Name at Birth, Maiden Names, etc.)
NOTE: Please enter N/A if this does apply to you.

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* Current Permanent Address:

No. and Street

City/Town

Province

Postal Code

Email Address

Phone Number

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* Gender:

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* Date of Birth

Date of Birth

Date

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* What is/are your club affiliation(s)?

	Primary Club	Other Club Affiliation	Other Club Affiliation
Club Affiliation	Club Affiliation Primary Club menu	Club Affiliation Other Club Affiliation menu	Club Affiliation Other Club Affiliation menu

Other (please specify)

Question Title

* What programs will you be coaching this season?


AquaGO!	AquaGO! menu
Recreation	Recreation menu
Limited Competitive	Limited Competitive menu
Provincial Stream	Provincial Stream menu
National Stream	National Stream menu
Masters Recreation	Masters Recreation menu
Masters Competitive	Masters Competitive menu
University (CUASL)	University (CUASL) menu

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* Did you know that coaches can work for or hold contracts with multiple clubs in the same province at the same time? This is permitted provided there are no conflicts of interest (i.e. coaching in the same age groups and events).

Do you consent for BC Artistic Swimming to share your personal contact information with member clubs who are seeking coaches for employment purposes?

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* If you answered yes, please provide the contact information you consent to be shared with member clubs seeking coaches for employment purposes.

Name (in full)

Email address

Phone number

Other (please specify)

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* NAME:

Question Title

* Other Names You Have Used (i.e. Given Name at Birth, Maiden Names, etc.)NOTE: Please enter N/A if this does apply to you.

Question Title

* Current Permanent Address:

Question Title

* Gender:

Question Title

* Date of Birth

Question Title

* What is/are your club affiliation(s)?

Question Title

* What programs will you be coaching this season?

Question Title

Question Title

* If you answered yes, please provide the contact information you consent to be shared with member clubs seeking coaches for employment purposes.

* Other Names You Have Used (i.e. Given Name at Birth, Maiden Names, etc.)
NOTE: Please enter N/A if this does apply to you.