2010-11 Local Program Renewal Application Survey

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Local Program Name:

Local Program Name:

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Please indicate your SOAZ Area: Mohave, Coconino, Yavapai, Gila/Payson, SNASO, Navajo Nation, Yuma, West Valley, Maricopa, East Valley, Central/Pinal, Pima, Cochise/Douglas, Cochise/Sierra Vista, Graham/Greenlee.

Area:

Please indicate your SOAZ Area: Mohave, Coconino, Yavapai, Gila/Payson, SNASO, Navajo Nation, Yuma, West Valley, Maricopa, East Valley, Central/Pinal, Pima, Cochise/Douglas, Cochise/Sierra Vista, Graham/Greenlee. Area:

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Please indicate your position with this Delegation

Please indicate your position with this Delegation Head of Delegation

Coach

Assistant Coach

Chaperone

Other (please specify)

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Please complete the following information for the Head of Delegation/Local Coordinator:

Please complete the following information for the Head of Delegation/Local Coordinator: Name:
Address:

City:
State:
ZIP/Postal Code:
Home Phone:
Work Phone:
Cell Phone:

Email Addresses

Email Addresses Email Address:
Alternate Email Address:

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Please list all of your Delegation's Coaches:
First Name, Last Name, Sport, Traditional/Unified/Both

Please list all of your Delegation's Coaches: First Name, Last Name, Sport, Traditional/Unified/Both

Please list any members of your Delegation that are Certified Sport Specific or Unified Sports Trainers:
First Name, Last Name, Sport

Please list any members of your Delegation that are Certified Sport Specific or Unified Sports Trainers: First Name, Last Name, Sport

To insure your Delegation's coaches are properly certified, or to check on coaches' certification status, please contact Jamie Heckerman, Sports & Training Manager, at 602.230.9135 or Jamie@SpecialOlympicsArizona.org.

2010-11 Local Program Renewal Application

Contact Information

*Local Program Name:

*Please indicate your SOAZ Area: Mohave, Coconino, Yavapai, Gila/Payson, SNASO, Navajo Nation, Yuma, West Valley, Maricopa, East Valley, Central/Pinal, Pima, Cochise/Douglas, Cochise/Sierra Vista, Graham/Greenlee.Area:

*Please indicate your position with this Delegation

*Please complete the following information for the Head of Delegation/Local Coordinator: