PCQ INDUSTRY EXPERIENCED COACH REQUEST

PCQ INDUSTRY EXPERIENCED COACH REQUEST
SECTION ONE - Club/Zone
Club/Zone*
e.g. Brookfield or Zone 1
Location of Activity:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Activity*

DayMonthYear
Date
Name of person co-ordinating the Activity*

First NameLast Name
Position in the Club/Zone of the person co-ordinating the Activity*
Name of Coach overseeing activity on the day of delivery of the Activity.*

First NameLast Name
Details of activity application area of specialist coaching e.g. showjumping, dressage, camp draft, stockman's challenge, etc.:*
Date of Management Meeting approving Activity.*

DayMonthYear
Date
Upload copy of Management Meeting Minutes identify and approval of Activity with Industry Experience Coach.*

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Signature of Club or Zone Chief Instructor approving application for Industry Experience Coach.*

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Signature of Club or Zone President approving application for Industry Experience Coach.*

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SECTION TWO - Industry Experienced Coach
Name of Industry Experience Coach*

First NameLast Name
Overview of Industry Experience in area of expertise*
Upload copy of current WORKING WITH CHILDREN CHECK (Blue Card) or exemption.

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Have you completed Child Safeguarding Training from Sport Integrity Australia?*

YES - please upload certificate of completion (below).NO - complete following screening questions
Child Safeguarding Online Training can be completed at https://elearning.sportintegrity.gov.au/login/index.php
Upload Child Safeguarding Certificate of Completion.

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Would you please tell us about your beliefs and values in relation to working with children?
Would you please tell us about your awareness and understanding of child protection?
Would you please tell us about your professional experience, competencies, and qualifications in relation to working with children?
What boundaries are important when working with children?
Have you ever had any disciplinary action taken against you in relation to you working with children?
Do you have a Public Liability Insurance:*

YesNo
Upload a copy of Public Liability Insurance Certificate of Currency (if available)

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Overview of Lesson Plan*
Steps to reduce risk mitigation.*
Declaration of the above information is true and correct. Signed by Industry Experienced Coach*

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