LIGHTHOUSE SOCCER CLUB

FALL 2008-2009 COACHES APPLICATION

 

MAIL TO: Lighthouse Soccer Club

PO Box 11562    Philadelphia, PA 19116

Visit us online at http://www.lighthousesoccer.org/

Call 215-441-1461 or 215-612-9813 for more info.

 

Last Name: ___________________________ First Name: _______________________________

Address: ______________________________________________________________________

Social Security #: _______________________________________________________________
(*needed for the EPYSA Risk management application, You cannot be considered an applicant for coaching per EPYSA and Lighthouse SC.)

Home Phone #: (_____) _______-__________                Cell Phone #: (_____) _______-__________

City: _________________________________    State: _______   Zip:_____________________

Sex:   M    F      Email: ___________________________________________________________

Medical Problems: ______________________________________________________________

Coaching Request  Age ____    Male  □    Female  □    Level:  Travel, Inhouse or TopSoccer

Playing Experience     Yes  □    No  □      

Where
When
Position
Level

 

Coaching Experience     Yes  □    No  □      

Where
When
Position
Level

Coaching Licenses and/or certifications     Yes  □    No  □      

Where
When
Position
Level

 

SIGNATURE: ______________________________________________________________

DATE: ___________________