AYSO REGION 42 -- NEWBURY PARK, CA -- 2005 REGION OF THE YEAR

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AYSO REGION 42
EXTRA PROGRAM COACH APPLICATION

PREREQUISITES FOR SUBMITTING AN APPLICATION TO COACH

Current AYSO Volunteer Application Form filed at National Support & Training Center

Compliant with training requirements for age of team being applied for per National and Section 10/Area 10E/Region 42 Program Guidelines (prior to start of season)

AYSO Safe Haven Certification

2 Years minimum coaching experience

Completed Application

Selection by Region 42 Extra Program Selection Committee

Regional Commissioner and Area Director Approval

APPLICANT'S INFORMATION
Full Name:
Street Address:
City:
State:
Zip:
E-mail:
Best Phone #:

POSITION REQUESTED

Gender and age of division you are requesting to coach in Extra (check all that apply)

BU-10	BU-11	BU-12	BU-13	BU-14
GU-10	GU-11	GU-12	GU-13	GU-14

What position are you interested in? Coach Asst. Coach Trainer Any

TRAINING (indicate highest level attained and year training completed)

AYSO Coach:

Year:

AYSO Referee:

Year:

USSF Coach:		#: Year:
Did you use the AYSO Reciprocity agreement for licensing? Yes No

EXPERIENCE

EXPERIENCE COACHING/TRAINING - AYSO

Region:

Division:

Fall All-Star
Spring Extra

Year:

Region:

Division:

Fall All-Star
Spring Extra

Year:

Region:

Division:

Fall All-Star
Spring Extra

Year:

Total years in coaching in AYSO:

EXPERIENCE COACHING/TRAINING - OTHER ORGANIZATIONS (USYS, US Club, SAY, etc):

Club:

Level:

Years (ie. 2007-2009):

Club:

Level:

Years (ie. 2007-2009):

Club:

Level:

Years (ie. 2007-2009):

Total years in coaching in other organizations:

Additional experience you consider relevant to your application to coach an Extra team:

REFERENCES:

Name:

Phone #:

E-mail address:

Name:

Phone #:

E-mail address:

Name:

Phone #:

E-mail address:

PLEASE SEND COPIES OF YOUR PROOF OF TRAINING/LICENSING & AYSO SAFE HAVEN CERTIFICATION COURSES, AS WELL AS ANY ADDITIONAL REFERENCE LETTERS, TO:
JO-ANNE GUERRIERE, EXTRA PROGRAM COORDINATOR