2022-2023 Coach Screening Disclosure Form Personal Information Question Title * NAME: First Name: Middle Name: Last Name: OK Question Title * Other Names You Have Used (i.e. Given Name at Birth, Maiden Names, etc.)NOTE: Please enter N/A if this does apply to you. OK Question Title * Current Permanent Address: No. and Street City/Town Province Postal Code Email Address Phone Number OK Question Title * Gender: Female Male Non-Binary Other (please specify) OK Question Title * Date of Birth Date of Birth Date OK Question Title * Primary Club Affiliation No Affiliation BC Aquasonics Caprice Artistic Swimming Haney Neptunes Kamloops Sunrays Kelowna Dolphins Nanaimo Diamonds Nelson Reflections Prince George Water Lilies Pacific Wave Synchro Ravensong Waterdancers Revelstoke Rainbows Vancouver Masters Synchro VanIsle Masters Vernon Silhouettes Victoria Synchro West Coast Masters Other (please specify) OK Question Title * Other Club Affiliation No Affiliation BC Aquasonics Caprice Artistic Swimming Haney Neptunes Kamloops Sunrays Kelowna Dolphins Nanaimo Diamonds Nelson Reflections Prince George Water Lilies Pacific Wave Synchro Ravensong Waterdancers Revelstoke Rainbows Vancouver Masters Synchro VanIsle Masters Vernon Silhouettes Victoria Synchro West Coast Masters Other (please specify) OK Question Title * Other Club Affiliation No Affiliation BC Aquasonics Caprice Artistic Swimming Haney Neptunes Kamloops Sunrays Kelowna Dolphins Nanaimo Diamonds Nelson Reflections Prince George Water Lilies Pacific Wave Synchro Ravensong Waterdancers Revelstoke Rainbows Vancouver Masters Synchro VanIsle Masters Vernon Silhouettes Victoria Synchro West Coast Masters Other (please specify) OK NEXT