For Members of the American Swimming Coaches Association5101 NW 21st Ave, Suite 530, Fort Lauderdale, FL 33309 Phone: 1 (800) 356-2722, (954) 563-4930 | Fax: (954) 563-9813 Email: asca@swimmingcoach.org | Website: www.swimmingcoach.org

PERSONAL DATAName

Address

City/State/Zip

Telephone Fax Email

Check the following Level for which you are applying: 1 2 3 3 E & E 4 4 E & E 5

Area for which you are applying: USA Swimming Age Group High School Junior College

NCAA I NCAA II NCAA III Stroke Coach (Level 3 only)

YMCA Senior YMCA Age Group Masters

EDUCATION1. List ALL college degrees (i.e., B.A. History, M.A. Physical Education, etc.)

College Degree: AA BA BS other (please specify)

Field of Study School Year

Additional Degrees Year

List any coaching-related elective courses taken OUTSIDE of a college degree:

Course School Credits QTR or Semester Year

2.

Clinic/Location Primary Speaker Number of Days Topics

OFFICEUSE ONLY

Academic Units

International

• JOIN ASCA AS A MEMBER. ONLY MEMBERS CAN BE CERTIFIED.• Complete this form as completely as possible so we can analyze your credentials.

• Privde copies of meet results or download athlete results page from web, to support achievement criteria.

• SCAN / EMAIL TO: CERTIFICATION@SWIMMINGCOACH.ORG• or FAX TO: (954) 563-9813• or MAIL TO: ASCA, Certification, 6750 N. Andrews Ave. Suite 200 Fort Lauderdale, FL 33309•

Date InstructorLevel 1 — The Foundation School DVD Level 2 — The Strokes SchoolLevel 3 — The Physiology SchoolLevel 4 — The Administration SchoolLevel 5 — The Leadership SchoolAdvanced BackstrokeAdvanced BreaststrokeAdvanced Butter�yAdvanced FreestyleAge Group Sports PsychologyCerti�ed Stroke Technician on DVDCoaching 8 & Under SwimmersCoaching the Novice Swim Team DVDDistance Based TrainingDistance Training School, Vol 1Distance Training School, Vol 2Drills and GamesDryland Training School,Dryland Training for Age GroupFundamentals for Competitive Swimming for 8 & Under SwimmersHow to Write Workouts Masters SchoolNewsletter and Bulletin Board CompanionNISCA ManualNutrition for SwimmersPersonal Organization for CoachesStrength & Flexibility Training for SwimmersTeaching Age Group Developmental Sports PsychologyTraining Age Group and Masters SwimmersVital ReadingWorking Successfully with Swimming ParentsWorkout ExchangeOther(s)

Positions Team Location Dates of Employment

1.

2.

ACHIEVEMENTWhen applying for Levels 3, 4 or 5, supply veri�cation of swim and Coach of Record.

Name of Athlete(s) Year Swim Meet/AGENCY Date(s)

DID YOU R EMEMBER TO Begin or renew your ASCA membership? You must be an ASCA member to be an ASCA Certi�ed Coach. Include an OVC or o�cial results for Certi�cation of Levels 3, 4 or 5? Include a letter from the Head Coach if you are not listed as the Coach of Record in the results you have sent?

OFFICEUSE ONLY

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I have held the following coaching positions (or include resume in place of this information): EXPERIENCE:

Please check all that apply with Date of Completion and Instructor.EDUCATION (CONT):OnlineOn-SiteHome Study