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TO ENROL Fill in the enrolment form and send it to the contact

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TO ENROL Fill in the enrolment form and send it to the contact Powered By Docstoc
					                     Community Coach Training Enrolment Form
                     Please complete the first three pages of this enrolment form only and mail to:
                                             Australian Sports Commission
                                                      PO Box 329
                                                 Leederville WA 6903
                                 For enquiries, phone: 9492 9769 or fax to: 9492 9770
  Enrolments close once a course reaches a maximum of 40 participants or 5pm one week prior to the
              course date, whichever comes first. Late registrations will not be accepted
 Once successfully enrolled in a course you will receive a confirmation letter outlining further details for
                      the day including exact location and parking instructions.

                         AASC Regional Coordinator Contact (if known): _______________________
           All participants are required to complete the Practical Course of the CCTP (Modules 1 and 5).
              If you are not eligible for automatic credit you will also be required to complete a Theory
                Course (Modules 2, 3 and 4). Details about individual modules are outlined on page 4.
          Please indicate which course/s you will be attending by ticking the box in the table below.
       PRACTICAL COURSES – EVERYONE IS REQUIRED TO ATTEND ONE OF THESE SESSIONS

  Course Name                               Venue/s                               Day             Dates           Times

  Swan Course                   Morley Sport and Recreation Centre
                                                                              Wednesday      September 30th   9:00am – 4:00pm
                                      Wellington Rd, Morley

Practical Course A                      Newman College
                                                                                Sunday         October 4th    8:30am – 3:30pm
                                    Tuscany Way, Churchlands

Practical Course B              Department of Sport and Recreation
                                                                                Monday         October 12th   9:00am – 4:00pm
                                  246 Vincent Street, Leederville


OSHCS PD Course                 Department of Sport and Recreation             Tuesday         October 20th   10:00 – 1:30pm
                                  246 Vincent Street, Leederville
                                                                              Wednesday        October 21st   10:00 – 1:30pm


THEORY COURSES – YOU MUST COMPLETE SHOULD YOU NOT HAVE AUTOMATIC CREDIT (see page 2)

                            Online Course         http://www.ausport.gov.au/coach/onlinecoachcourse.asp



 **If you elect to complete the online Course YOU WILL BE REQUIRED TO PROVIDE PROOF OF COMPLETION (CERTIFICATE)


                                                   PERSONAL DETAILS

          FIRST NAME: __________________________                 LAST NAME: ____________________________________

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

          TELEPHONE: (W)_______________________ (H) _______________________________

          TELEPHONE: (M) _______________________________ FAX: _____________________

          EMAIL ADDRESS: _________________________________________________

          POSTAL ADDRESS: ______________________________________________________

          TOWN/SUBURB:________________________POSTCODE: ______________________

          HOME 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)

Please list the School/OSHCS name: _____________________________________________________

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


Please list the organisation name: _______________________________________________________


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



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


Preferred Locations for coaching: (if not a school/OSHCS employee)
     □    Canning East Region – Vic Park, Cannington, Gosnells, Kalamunda and in between.
     □    Canning West Region – South Perth, Riverton, Armadale, Roleystone and in between.
     □    Swan East Region – Morley, Bassendean, Ellenbrook, Bullsbrook, Mt Helena and in between.
     □    Swan West Region – Balga, Bayswater, Mt. Lawley, Yokine, Joondanna, Ballajura and in between.
     □    West Coast South Region – Subiaco, Scarborough, Hillarys, Whitfords and in between.
     □    West Coast North Region – Joondalup, Wanneroo, Hillarys, Two Rocks and in between.
     □    Fremantle North Region – Cottesloe, Coolbellup, Leeming, South Perth and in between.
     □    Fremantle/Peel Region – Mandurah, Baldivis, South Lake and in between.
                                                 Active After-school Communities
                                                           PO BOX 329
                                                     LEEDERVILLE WA 6903
                       General Enquiries: Kelly Dalgleish 9492 9769 • Facsimile 9492 9770
                                  PROHIBITED PERSONS SCREENING


Please note that all deliverers in the Active After-school Communities program must have
appropriate police clearances in place. Please tick the one which you require.

If you already have appropriate clearance, please send a copy with your enrolment form or
bring it with you on the day of the course.
            □                             □                                         □                   □
           WACOT                       Working With                           Crimtrac       Not Applicable
          Registration            Children Check (WWCC)                                     (Only if under 18
                                                                                            and a volunteer)



                                           MEDICAL CONDITIONS

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:
                      _________________________________________________________________________

                      _________________________________________________________________________



                              APPLICANTS RELEASE AND ACCEPTANCE


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:____________________


                                                 Active After-school Communities
                                                           PO BOX 329
                                                     LEEDERVILLE WA 6903
                       General Enquiries: Kelly Dalgleish 9492 9769 • Facsimile 9492 9770
           COMMUNITY COACH TRAINING PROGRAM – MODULE OUTLINE


Module 1 – Active After-school Communities Program overview
This module will provide participants with a clear understanding of the AASC program, their role
and responsibilities within the program, and the philosophy of the Playing for Life approach.

They will also have an understanding of how to develop sessions that engage and motivate
primary school-aged children to participate in physical activity, and barriers to participation.

Module 2 – Communication and behaviour management
Successful completion of this module will enable participants to develop strategies for
communicating effectively with, and managing groups of, primary school-aged children.
Participants will also be able to communicate effectively with other AASC stakeholders.

Module 3 – Safe Environments
This module will enable participants to identify and implement the necessary steps to minimise
the risk of injury and to manage injuries or emergency situations if they arise.

Module 4 – Nutrition and Well Being
At the conclusion of this module participants will be able to provide basic information to primary
school-aged children on nutrition and well being.

Module 5 – Planning, preparing, delivering and reviewing Playing for Life activity
sessions
This practical based module will enable participants to effectively plan, prepare, deliver and
review Playing for Life activity sessions.

Assessments
All participants must complete a brief ten minute practical assessment, demonstrating the
Playing for Life approach for successful completion of the Community Coach Training Program.




                                           Active After-school Communities
                                                     PO BOX 329
                                               LEEDERVILLE WA 6903
                 General Enquiries: Kelly Dalgleish 9492 9769 • Facsimile 9492 9770

				
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Description: TO ENROL Fill in the enrolment form and send it to the contact