Form Ed 186 PDF Details

Form Ed 186 is a document that all postsecondary institutions in Alberta must complete for each international student they enrol. This form helps ensure that postsecondary institutions are meeting their obligations under the Immigration and Refugee Protection Act (IRPA) and associated regulations. Completing Form Ed 186 is important for both postsecondary institutions and international students, as it helps to ensure a positive experience for everyone involved. In this blog post, we will discuss what Form Ed 186 is, why it is important, and how to complete it.

These are some information regarding form ed 186. Our advice is that you look at this info before you begin filling out the form.

QuestionAnswer
Form NameForm Ed 186
Form Length4 pages
Fillable?Yes
Fillable fields170
Avg. time to fill out35 min 4 sec
Other namescoaching certification ct, state of ct emergency coaching permit form 186 online, ct temporary coaching permit, state of ct ed 186

Form Preview Example

 

 

 

 

ED 186

CONNECTICUT STATE DEPARTMENT OF EDUCATION

 

 

 

REV. 7/19

Bureau of Educator Standards and Certification

 

 

C.G.S. 10-145

P.O. Box 150471

C.G.S. 10-145d

Hartford, CT 06115-0471

C.G.S. 10-149

C.G.S. 10-149b

www.ct.gov/sde/cert

Regs. 10-145d-424

 

 

 

 

APPLICATION FOR TEMPORARY EMERGENCY COACHING PERMIT

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LAST NAME

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FIRST NAME

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MI

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

GENDER

 

 

 

 

 

 

 

˗

 

 

 

 

 

 

 

˗

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

˗

 

 

 

 

 

 

 

 

˗

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SOCIAL SECURITY NUMBER

 

 

 

 

 

BIRTH DATE (Month-Day-Year) - Required

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ADDRESS (Street)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Apt. #

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(City)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(State)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

˗

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FORMER LAST NAME(S)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Zip Code)

˗

 

 

 

 

 

 

 

 

 

 

 

 

 

 

˗

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PHONE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Home)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Race/Ethnicity 1.

Native American

 

 

 

 

 

 

 

 

 

 

 

 

 

 

˗

 

 

 

 

 

 

 

 

 

 

 

 

 

 

˗

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2.

 

Asian/Pacific Islander

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3.

 

Black

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Work)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4.

 

White

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Optional)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5.

 

Hispanic

E-MAIL ADDRESS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1. Have you ever been convicted of any crime, excluding minor traffic violations?

 

 

 

YES

 

 

 

 

 

 

 

 

NO

2. Have you been dismissed for cause from any position?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

 

 

 

 

 

 

 

 

NO

3. Have you ever surrendered a professional certificate, 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 submit, periodically, a database of applicants for an initial issuance of a certificate, authorization or permit to the State Police Bureau of Investigation for a criminal history record check. Each applicant seeking an initial issuance or renewal of a certificate, 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 criminal history records check the database of all persons who hold any certificate, 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 official copies of court or administrative record(s), including disposition of each use.

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

PAGE 1

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.

 

 

 

Name of course completed

Date of completion

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.

Name of course completed

Date of completion

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 OF APPLICANT:

DATE:

Original Signature Must Be On Form Submitted

PAGE 2

ED 186

PART VIII: EMPLOYING AGENT ATTESTATION

A. Check one:

Initial Permit

Renewal

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:

Signature of Superintendent, Executive Director or Designee

Date

(Original Signature: No Signature Stamps Accepted)

 

 

 

 

 

Type or Printed Name of Person Signing Above

 

 

Title

Employing Agent

 

 

 

Telephone

Street

 

 

 

 

 

 

 

E-mail Address

City

State

Zip Code

 

PAGE 3

ED 186

CONNECTICUT STATE DEPARTMENT OF EDUCATION

REV. 7/19

Bureau of Educator Standards and Certification

C.G.S. 10-145

P.O. Box 150471

C.G.S. 10-145d

Hartford, CT 06115-0471

C.G.S. 10-149

C.G.S. 10-149b

www.ct.gov/sde/cert

Regs. 10-145d-424

 

 

INSTRUCTIONS TO APPLICATION FOR

 

TEMPORARY EMERGENCY COACHING PERMIT

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.

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ed 186 ct sde empty fields to consider

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The program will request you to insert certain essential info to automatically complete the section Name, of, course, completed Date, of, completion Name, of, course, completed Date, of, completion and PART, IV, HIGHSCHOOL, INFORMATION

Finishing ed 186 ct sde part 3

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Finish by analyzing the next sections and preparing them accordingly: PART, VIII, EMPLOYING, AGENT, ATTESTATION A, Check, one Initial, Permit Renewal, Employing, Agent Street, Date, Title, Telephone, Email, Address City, State, and Zip, Code

ed 186 ct sde PARTVIIIEMPLOYINGAGENTATTESTATION, ACheckone, InitialPermit, Renewal, EmployingAgent, Street, Date, Title, Telephone, EmailAddress, City, State, and ZipCode fields to fill out

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