Form Ed 186 – Fill Out and Use This PDF

ED 186

PART II: COMPLETION OF REQUIRED FIRST AID COURSE

The first aid course must have been completed with 1 year prior to the date of application. Please sign your first aid card and attach: (1) a photocopy of both the front and back of the first aid card, or (2) original certificate of completion, to this application.

PART III: COMPLETION OF REQUIRED CPR COURSE

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

PART IV: HIGH SCHOOL INFORMATION

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

PART V: CONCUSSION AND HEAD INJURY TRAINING REQUIREMENT

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

PART VI: RENEWAL OF COACHING PERMIT

Complete this section ONLY if you are requesting renewal of the Temporary Emergency Coaching Permit.

1.Provide proof of enrollment in an approved coaching course;

OR

2.Attach an official transcript verifying the completion of at least two (2) semester hours of credit in an approval coaching course;

OR

3.Provide verification of completion of 30 clock hours of instruction in an approved coaching course.

PART VII: APPLICANT ATTESTATION

I have reviewed this application and affirm that the information provided by me on this application and any accompanying documents contains no material misrepresentations, falsifications or omissions and that all the information given by me is true, complete and accurate. I understand that all application and accompanying information may be verified and that any material misrepresentation, falsification or omission may result in the denial or revocation of my certificate(s), permit(s) or authorization(s).

By checking the "I Agree" box, you agree your typed signature is the legal equivalent of your manual signature on this Application. I Agree.

Original Signature Must Be On Form Submitted

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ED 186

PART VIII: EMPLOYING AGENT ATTESTATION

I am requesting issuance of a Temporary Emergency Coaching Permit for the _________________ school year. This request is made on

the basis of my determination that no certified teacher possessing a coaching permit or noncertified individual possessing a coaching permit is available for the position and that the applicant meets all requirements for issuance of the permit. The applicant will be supervised and assisted, as appropriate, by regular observation, guidance and evaluation of performance.

B. For RENEWAL request, also complete this section:

Renewal of the Temporary Emergency Coaching Permit is requested for the following school year:_________________________

The applicant has served successfully as a coach during the school year:__________________________________

C.Signature of Superintendents or Designee required for all requests:

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Applicant:

For the ISSUANCE of the Temporary Emergency Coaching Permit you must complete and submit the following:

a. Complete Parts I through V, and Part VII.

b. Attach a photocopy of your Standard First Aid card, or original certificate of completion, verifying the successful completion of the Standard First Aid course within one year prior to the date of application. Please remember to sign your Standard

First Aid card prior to photocopying.

c. Attach a photocopy of your CPR card, or original certificate of completion, verifying the successful completion of the CPR course within one year prior to the date of application. Please remember to sign your CPR card prior to photocopying.

d. Attach a photocopy of your high school diploma or its equivalent. Your official high school transcript may be submitted in lieu of a copy of your diploma.

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

f. Return completed application to the superintendent of schools.

For the RENEWAL of the Temporary Emergency Coaching Permit, please complete Parts I, through III, V, through VII.

Employing Agent:

For the ISSUANCE of the Temporary Emergency Coaching Permit:

a.Complete Part VIII, sections A and C. Please mail application and supporting documentation to the Bureau of Educator Standards and Certification.

For the RENEWAL of the Temporary Emergency Coaching Permit:

b.Complete Part VIII, sections A, B, and C. Please mail application and supporting documentation to the Bureau of Educator Standards and Certification.

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