Coach Training Form

Date*

Name*

First Last

Mailing Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Select the option that best describes where you live.*

Primary Phone*

Other Phone

Email*

Please indicate your prefered method of contact*

Do you have an Intellectual or Developmental Disability?*

Yes
No

Do you know someone who does have an Intellectual or Developmental Disability?*

Yes
No

Please check any Race/Ethnicity that best describes you.*

Caucasian
African American
Native American
Hispanic/Latino
Asian
Pacific Islander
Two or more races
Other
Prefer not to say

Please choose the option that best describes you.*

Do you have a valid VA Drivers License?*

Yes
No

Do you have your own transportation to volunteer sites?*

Yes
No

Educational Background

Check all that apply.*

Applied Studies High School Diploma
Modified Standard HS Diploma
Standard High School Diploma
GED
Vocational/Trade School
College

Highest Grade Completed

Certifcation/Licensure

Do you have First Aid Training?*

Yes
No

Expire Date for First Aid Training

Are you CPR Certified?*

Yes
No

Expire Date for CPR Certification.

Do you have Military Experience?*

Yes
No

Active Duty Military?

Yes
No

Retired Military?

Yes
No

College Attendance (If Applicable)

College 1:

City/State

Dates of Attendance

Degree/Major

College 2:

City/State

Dates of Attendance

Degree/Major

Volunteer Details

Please indicate an area you are interested in volunteering, i.e. working with animals, ethics work, working with people.*

Select the days you are available to volunteer.*

Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

Provide specific times you are available on the days indicated above.*

Let us know if you need help with....

Mobility
Reading
Standing for long periods
Other

Please share about the 'other' you selected above.

Have you ever been convicted of a felony?*

Yes
No

Provide detail of your felony conviction. Date, City/State of conviction and reason for conviction.