USA HOCKEY
Coaching Education Program

Request for District Temporary Coaching Card

Date ___________________________ Current Season ___________________________________

Name ______________________________________Soc. Sec. # ____________________________

Address ____________________________________ Date of Birth ___________________________

City ___________________________________ State ____________________ Zip ______________

Home Phone ___________________________ Work Phone ________________________________

Fax Number _____________________________ E-Mail ____________________________________

Association __________________________ Team Level & Name ____________________________

District ________________________________ Affiliate _____________________________________

Date, Level, & Locations of
Clinics Attended _________________________________________________________________

CEP Card Number ____________________
 Enclosed is a check or money order for $ 50.00 made payable to USA Hockey

I understand that the Temporary USA Hockey Coaching Card is only valid through May 30th of this season. I also understand that I may only apply once for a Temporary Coaching Card throughout my career as a USA Hockey coach, and that I must fulfill the necessary requirements of my District / Affiliate after May 30th of the current season. Failure to fulfill the necessary requirements results in forfeiture of all of my coaching certification.

Signature of Coach _____________________________________ Date _______________________