PACIFIC SOCCER CLUB SOUTH

AYSO SIMI EXTRA / UNITED COACH APPLICATION PRE REQUISITES FOR SUBMMITTING an APPLICATION TO COACH EXTRA:  Current registered AYSO Volunteer in the current Membership Year  Compliant with training requirements for age of team being applied for per Section 10 guidelines (prior to start of season)  AYSO Safe Haven Certification  CDC Concussion Training  2 Years minimum coaching experience  Extra Committee recommendation  Regional Commissioner & Area Director Approval UNITED: (in addition to the above):  Compliant with training requirements for age of team being applied for per Coast Soccer League & Cal South guidelines  Cal South KIDSAFE Risk Management screening  Must commit to having a fully certified Assistant Coach & Team Manager per Cal South guidelines noted above  Must commit to all referee volunteer obligations required by the “Give Back” to the core region provision, as noted in the Region 121 United Guidelines  Must commit to supporting AYSO Philosophies at all times  Challenge Committee recommendation APPLICANT’S INFORMATION Full Name: ________________________________________________________________ Mailing Address:____________________________________________________________ City, State, Zip ___________________________________________________________ E-mail Address: ____________________________________________________________ Best Phone #: _________________________ TRAINING (Mark highest attained and year training completed) AYSO Coach:

U-12

USSF Coach:

E

Youth D-State

Intermediate D- Nat’l

C

Advanced B

A

Did you use the AYSO Reciprocity agreement for licensing? AYSO Referee:

Regional

Intermediate

National

Year: ______

# __________Year: ________ Yes

Advanced

Page 1 of 2 EXTRA/UNITED COACH APPLICATION 2017

No ____________ National

Year _________

EXPERIENCE Experience Coaching/Training – AYSO Region: ___________ Division: ____

Fall

All-Star

Spring

Plus

Year: ________

Region: ___________ Division: ____

Fall

All-Star

Spring

Plus

Year: ________

Region: ___________ Division: ____

Fall

All-Star

Spring

Plus

Year: ________

Total years in coaching in AYSO _________ Experience Coaching/Training – Other Organizations (USYS, US Club, USSF, etc): AYSO EXTRA: ________________ Level: ______________ Years: _______- _________ AYSO Challenge: ______________ Level: ______________ Years: _______- _________ Club: ___________________ Level: ______________ Years: _______ - _________ Club: ___________________ Level: ______________ Years: _______ - _________ Club: ___________________ Level: ______________ Years: _______ - _________ Total years coaching in other organizations ________ Gender and age of division being requested to coach in EXTRA or United (Check age division(s): BU-10

BU-11

BU-12

BU-13

BU-14

BU-15

BU-16

GU-10

GU-11

GU-12

GU-13

GU-14

GU-15

GU16

Additional experience you consider relevant to your application to coach an EXTRA or United team:

(If you require more space, please attach additional paperwork to your application when submitted)

REFERENCES: Name 1.

Phone #

E-mail Address

______________________________________________________________________________________________________

2. ______________________________________________________________________________________________________ 3. ______________________________________________________________________________________________________

PLEASE ATTACH PROOF OF COMPLETION OF TRAINING/LICENSING AND SAFE HAVEN CERTIFICATION COURSES AS WELL AS ANY ADDITIONAL REFERENCE LETTERS. RETURN COMPLETED APPLICATION TO: [email protected] [email protected] OR MAIL TO: AYSO REGION 121 COACH APPLICATION P.O. BOX 940298 SIMI VALLEY CA 93094 Page 2 of 2 EXTRA/UNITED COACH APPLICATION 2017