Connecticut Form Ed 185 – Fill Out and Use This PDF

ED 185	CONNECTICUT STATE DEPARTMENT OF EDUCATION
REV. 1/12	Bureau of Educator Standards and Certiication

Regs. 10-145d-423	www.ct.gov/sde

APPLICATION FOR FIVE-YEAR RENEWABLE COACHING PERMIT

PART I: PERSONAL INFORMATION (Print all information in blue ink and in uppercase letters.)

FORMER LAST NAME(S)

–

(State)

(Zip Code)

PHONE

–

–

Race/Ethnicity

1.

Native American

(Home/Cell)

2.

Asian/Paciic Islander

3.

Black

E-MAIL ADDRESS

(Optional)

4.

White

5.

Hispanic

1.

Have you ever been convicted of any crime, excluding minor trafic violations?

YES

NO

2.

Have you ever been dismissed for cause from any position?

YES

NO

3.

Have you ever surrendered a professional certiicate, license, permit or other credential

YES

NO

(including, but not limited to, an education credential); had one revoked, suspended,

annulled, invalidated, rejected or denied for cause; or been the subject of any other

adverse or disciplinary credential action?

Pursuant to Connecticut General Statutes Section 10-221d, the State Board of Education must complete a criminal history records check on each applicant for an initial issuance or renewal of a certiicate, authorization or permit. Each applicant seeking an initial issuance or renewal of a certiicate, authorization or permit must also submit to a records check of the Department of Children and Families’ child abuse and neglect registry established pursuant to Connecticut General Statutes Section 17a-101k. In addition, the State Board of Education is required to submit periodically for a criminal history records check the database of all persons who hold any certiicate, authorization or permit.

NOTE: If you answer “YES” to any of the above questions, you must attach a signed statement of explanation. If there are multiple incidents within each question, you must list and explain each separately. Submit oficial copies of court or adminis- trative record(s), including disposition of each case.

Information on this application is subject to disclosure pursuant to the Freedom of Information Act.

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ED 185

PART II: COMPLETION OF REQUIRED FIRST AID COURSE

The irst aid course must have been completed within 3 years prior to the date of application. Please sign your irst aid card and attach: (1) a photocopy of both the front and back of the irst aid card, or (2) original certiicate of completion, to this application.

Name of course completed

Date of completion

PART III: COMPLETION OF REQUIRED CPR COURSE

Please sign your valid CPR card and attach: (1) a photocopy of both the front and back of the CPR card, or (2) original certiicate of completion, to this application.

Name of course completed

Date of completion

PART IV: HIGH SCHOOL INFORMATION

Please attach a copy of your high school diploma or oficial high school transcript to this application.

PART V: CONCUSSION AND HEAD INJURY TRAINING REQUIREMENT

Attach the original certiicate of completion of the concussion and head injury training requirement (Module 15) from the Connecticut Coaching Education Program (CCEP).

PART VI: COMPLETION OF REQUIRED COACHING COURSE

(For individuals NOT holding a valid Connecticut educator certiicate, or a standard or permanent certiicate)

Course completed at:		Date course completed:
	(Name of college/university or board of education)

On or after July 1, 2010, through June 30, 2015, completion of the concussion and head injury training requirement (Module 15) from the Connecticut Coaching Education Program (CCEP).

After July 1, 2015, completion of the refresher course completed through the CCEP.

PART VIII: APPLICANT ATTESTATION

I certify that the information provided by me on this application and any accompanying documents contains no material misrepresentations, falsiications or omissions and that all of the information given by me is true, complete and accurate. I understand that all application and accompanying information may be veriied and that any material misrepresentation, falsiication or omission may result in the denial or revocation of my certiicate(s), permit(s) or authorization(s). I further certify that I have attained the age of at least 18 years.

Original Signature Must Be On Form Submitted

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ED 185 CONNECTICUT STATE DEPARTMENT OF EDUCATION

REV. 1/12	Bureau of Educator Standards and Certiication
C.G.S. 10-145

Listed below are the required documents which must be submitted to the Bureau of Educator Standards and Certiication to process your request for the issuance or renewal of a Five-Year Renewable Coaching Permit.

For the ISSUANCE of a Five-Year Renewable Coaching Permit you must complete and submit the following:

Applicant:

1. If you do NOT hold a valid Connecticut educator certiicate, or a standard or permanent certiicate, please com- plete sections a through g of the instructions below.

2. If you hold a valid Connecticut educator certiicate, or a standard or permanent certiicate, please complete sec- tions a, b, c, f and g of the instructions below.

Instructions:

a. Complete Parts I through VI and Part VIII of the application. (Applicants who hold a valid Connecticut educator certiicate, or a standard or permanent certiicate, need not complete Parts IV or VI).

b. Attach a photocopy of your valid Standard First Aid card, or original certiicate of completion. The Standard First Aid course must be completed within three years prior to the date of application. Please remember to sign your

Standard First Aid card prior to photocopying.

c. Attach a photocopy of your valid CPR card, or original certiicate of completion. Please remember to sign your

CPR card prior to photocopying.

d. Attach a photocopy of your high school diploma or its equivalent. An oficial high school transcript may be sub-

mitted in lieu of a copy of your diploma.

e. Oficial transcript/certiicate verifying the completion of an approved coaching course.

f. Attach the original certiicate of completion of the concussion and head injury training requirement (Module 15) from the Connecticut Coaching Education Program (CCEP).

g. Return completed application and attachments to the Bureau of Educator Standards and Certiication.

(continued)

Information on this application is subject to disclosure pursuant to the Freedom of Information Act.