USA HOCKEY COACHING EDUCATION PROGRAM

REPLACEMENT CARD FORM

Please note that this form is to be used to replace your coaching certification card, not your general membership card.  Coaching cards are issued at the completion of a USA Hockey Coaching Clinic and are blue in color.

Please fill out the following information and print neatly in ink.  The information being asked for is pertinent to finding your record on the database.  Information not provided may hinder our ability to find your coaching record.

CEP # (If known):_____________                          BIRTHDATE ___/_____/_____

Name:________________________________________________________________

Address:______________________________________________________________

City:________________________ State:_________________     Zip:_______________

Home Phone:_________________________  Work Phone:__________________

Fax:___________________       Email address:________________________________

Clinic(s) Attended:

Location:_____________________      Level:________________ Year:__________

Location:_____________________      Level:________________ Year:__________

Location:_____________________      Level:________________ Year:__________

Location:_____________________      Level:________________ Year:__________

Level 1:                                    If you have moved since your last clinic,

Level 2:                                    please provide previous address:

Level 3:                                    ___________________________________

Level 4:                                    ___________________________________

Level 5:                                    ___________________________________

Please send check or money order for $5.00 made payable to USA Hockey and mail to:

Alison Raines

USA Hockey Coaching Education Program

1775 Bob Johnson Drive

Colorado Springs, CO  80906