Application for Sports Training Certification

Fields in bold are required.

First name

Last name

Daytime phone

- - x

Evening phone

- - x

Cell phone

- - x

Address

This address has changed since my last certification.

City

State

Zip code

Gender

female
male

General Orientation / Protective Behaviors

I completed a Special Olympics Minnesota General Orientation
I completed the Special Olympics International online Protective Behaviors training

I completed a Training Seminar/Course
Date	,
Location

I am applying for certification in the following area

Level II
	Sport:

Level II Recertification / Level III
	Principles of Coaching
	Coaches Meeting Recertification
	CPR / First Aid Training
	Other:

I am currently certified in the following sport(s)

Practicum

A minimum of 10 hours working with Special Olympics athletes following a coach training seminar is required. Officials, Competition Management members, and Games Management Team members may include a minimum of 10 hours in preparing for and/or conducting competition.

Practicum 1
Date	,
# of hours
# of athletes

Practicum 2
Date	,
# of hours
# of athletes

Practicum 3
Date	,
# of hours
# of athletes

Practicum 4
Date	,
# of hours
# of athletes

Practicum 5
Date	,
# of hours
# of athletes

Practicum 6
Date	,
# of hours
# of athletes

Practicum 7
Date	,
# of hours
# of athletes

Practicum 8
Date	,
# of hours
# of athletes

Practicum 9
Date	,
# of hours
# of athletes

Recognition Items

I'd like to receive the following recognition item for Level II certification

Polo - size
Padfolio
Briefcase
Hat

I'd like to receive the following recognition item for Level II recertification or Level III certification

Denim shirt - size
Fleece vest - size
Zippered padfolio
Stopwatch
Clipboard
6lb shot put
8lb shot put
Relay batons
Ball bag
30m measuring tape

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