EB CoachOfficial form

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					                                                                                    COACH & OFFICIAL REGISTRATION & AFFILIATION FORM 2009-2010
                                         COACHES & OFFICIALS: Please complete this form in UPPER CASE and send it to London Registrar, 48 Castleton Road, Eastcote, Middx. HA4 9QL with the correct fees. Cheques should be made payable to
                                         London Region Basketball Leagues. We will return your individual membership card. Please sign and retain this card.

                      Are you a member of a club? - CLUB ASSOCIATION

                     FIRST NAME                                                                                                                                                                                                       GENDER

                     LAST NAME                                                                                                                                                                         DATE OF BIRTH             dd-mm-yyyy
                    FULL ADDRESS                                                                                                                                                                      POSTCODE

                        EMAIL                                                                                                                                            Contact Phone No
                                         Codes - White; British White (W), Irish White (WI), Other White (WO). Mixed; White & Black Caribbean (MBC), White
                                                                                                                                                               Do you have any long-term illness or health      Do you have any disability which limits your daily
                                          & Black African (MBA), White & Asian (MA), Other Mixed (MO), Asian (A), Indian (I), Pakistani (P), Bangledeshi (B)
                                                                                                                                                               problems which limits your daily activities?                       activities?
                                                  Other Asian (AO). Black; Black Caribbean (BC) , Black African (BA), Other Black (OB). Chinese (C)

                                                                                                                           PLEASE USE DROP DOWN MENUs
                                             (L1=Assistant Coach, L2=Club Coach, L3=Advanced Coach,
                 COACH Qualification
                                                              SENIOR=Senior Coach)
                                                                                                                                                                          Please list the teams
                                                                                                                                                                             that you coach
                 ACTIVELY COACH IN       If you are an Active Coach please indicate the level(s) you coach at

                                                     Frequency with which you coach per week                                                                            As a Coach this license entitles you to coach in any affiliated local league game, schools
                   (Hours per Week)
                                                                                                                                                                        competitions and BUSA games (subject to qualification and level.) For more information
                 PAID or VOLUNTARY                       Primarily a paid or voluntary coach?                                                                                     please visit the Coaching section on

                                         (L1=Apprentice Referee, L2=Level 2 Referee, L3=Level 3 Referee,
                 REFEREE Qualification
                                                    L4=Level 4 Referee or L5=FIBA Referee)
                                                                                                                                                                           Please list the local
                                                                                                                                                                          leagues in which you
                                         If you are an Active Referee please indicate the level(s) you referee

                  ACTIVELY REFEREE                                                                                                                                              officiate

                     FREQUENCY                                                                                                                                          As a Referee or Table Official this license entitles you to Officiate in any affiliated Local
                                                          Frequency with which you referee
                  (Games per Week)                                                                                                                                      League game, National League age group games, Schools competitions and also BUSA
                                                                                                                                                                           games (subject to qualification and level). For more information please visit the
                 PAID or VOLUNTARY                      Primarily a paid or voluntary referee?
                                                                                                                                                                                         Officiating section on
                   TABLE OFFICIAL              (L1=Apprentice Table Official, L2=Level 2 Table Offical
                                                                                                                                                                                                       Where your money goes:
                     Qualification                         or L3=Level 3 Table Official)
                                                                                                                                                                               Insurance                    £6.00             Additional Insurance Top Up

                   ACTIVELY TABLE         If you are an Active Table Official please indicate the level(s) you
                     OFFICIATE                                       officiate at
                                                                                                                                                                               Retained Locally             £2.40             Senior top up             £20
                                                      Frequency with which you table officiate                                                                                 England Basketball           £3.60             Under 18 top up           £15
                  (Games per Week)
                 PAID or VOLUNTARY                    Primarily a paid or voluntary table official?                                                                                                                           Please include the additional
                                                                                                                                                                                                                                   payment with your
                                                                                                                                                                               Total                       £12.00                   registration fee
                                              (C TUTOR=EB Coach Tutor, R TUTOR=EB Referee Tutor,                                                                         Uner 18 coach / officials can register                    OFFICE USE ONLY
                      EB TUTOR

                                                      TO TUTOR=EB Table Official Tutor)                                                                                  for £5.00. As they cannot be covered
                       TEACHER                     Please select Y if appropriate                                STATISTICIAN    Please tick if appropriate               by the Personal and Public Liability
                                                                                                                                                                             Insurance that senior coach /
                                                                           If you are playing as well as coaching & or officiating please indicate                                  officials receive.

DATA PROTECTION: Any information provided by you will be held by England Basketball on its computer records. We will from time to time send you electronic communication via email. If you do not want to receive these
communications please tick the DP box.

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