ACTIVITY COACH APPLICATION FORM (Monarch System Training)
Date of Application: Click or tap to enter a date
INFORMATION
First Name:	Click or tap here to enter text.
Last Name:	Click or tap here to enter text.
Current Primary Employer:	Click or tap here to enter text.
Cell Phone:	Click or tap here to enter text.
Work Phone:	Click or tap here to enter text.
Email:	Click or tap here to enter text.
TELL US ABOUT YOU
Brief background & career history related to healthcare and/or fitness (i.e. degrees, titles, key responsibilities):	Click or tap here to enter text.
Healthcare and/or fitness qualifications:	Education (Please list):
Click or tap here to enter text.
Certifications and, or certifications in process (Please list): Click or tap here to enter text.
Areas of healthcare and/or fitness expertise:	Click or tap here to enter text.
Coaching/behavioral change experience: (If any)	Click or tap here to enter text.
Number of years of experience in healthcare and/or fitness:	Click or tap here to enter text.
Outside interest or hobbies:	Click or tap here to enter text.
What are you most passionate about around personal wellness and/or health promotion?	Click or tap here to enter text.
Will you commit to providing 12-weeks of pro bono coaching per client (minimum of 12 coaching sessions per client for 30 mins each, introductory session may be 60-90 mins.)?	If YES, how many clients would you be willing to coach at one time? Click or tap here to enter text. How many participants would you be willing to coach in total? Click or tap here to enter text. If NO (Please let us know what you are willing to volunteer) Click or tap here to enter text.
Insurance	Do you carry Commercial and General Liability (CGL) or Professional Liability (PL) Insurance to a minimum of $2,000,000? Please Note: Liability Insurance is not mandatory for the Volunteer coaching. However, you should have liability insurance if your client carries on a business relationship with you after the trial sessions.
REPORTING
Study Information	Are you willing to participate in research surveys as part of the evaluation process?
SUBMIT INSTRUCTIONS
Engagement Summary	1. SAVE YOUR APPLICATION using the following format so we can easily identify it: eg. JohnSmith-ActivityCoachApplication.doc 2. EMAIL as an attachment to: alberta@prescriptiontogetactive.com

If you have any questions about the application or our program, please contact:

Jeff Tareta, Executive Director

Email: alberta@prescriptiontogetactive.com

Phone: 1-866-212-7552 ext. 1

Or

Lisa Dare (Activity Coaching Chair)

Email: ld_assoc@telus.net