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The Connecticut Ed 185 form is an essential document for individuals seeking to obtain or renew a Five-Year Renewable Coaching Permit. This application serves multiple purposes, including the verification of personal information, completion of required training, and adherence to state regulations. Applicants must provide their personal details, including name, address, and contact information, while also disclosing any past criminal convictions or professional disciplinary actions. This transparency is crucial as the State Board of Education conducts thorough background checks, including a review of criminal history and child abuse registries, to ensure the safety of students. Additionally, the form requires proof of completion for various training courses, such as First Aid, CPR, and concussion awareness, which are vital for coaching safely and effectively. For those not holding a valid Connecticut educator certificate, additional documentation regarding coaching courses is necessary. The renewal process also mandates proof of ongoing education, ensuring that coaches remain informed about best practices in youth sports. Completing the Ed 185 form accurately and thoroughly is not just a bureaucratic step; it is a commitment to fostering a safe and supportive environment for student-athletes.

Connecticut Ed 185 Example

 

 

 

 

ED 185

CONNECTICUT STATE DEPARTMENT OF EDUCATION

 

 

 

REV. 1/12

Bureau of Educator Standards and Certiication

 

 

 

C.G.S. 10-145 C.G.S. 10-145d

P.O. Box 150471 – Room 243

C.G.S. 10-149 C.G.S. 10-149b

Hartford, CT 06115-0471

Regs. 10-145d-423

www.ct.gov/sde

 

APPLICATION FOR FIVE-YEAR RENEWABLE COACHING PERMIT

PART I: PERSONAL INFORMATION (Print all information in blue ink and in uppercase letters.)

LAST NAME

FIRST NAME

–

 

 

 

–

 

 

 

 

 

SOCIAL SECURITY NUMBER

ADDRESS (Street)

(City)

MI

 

 

GENDER (M/F)

–

 

 

 

–

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

BIRTH DATE (Month-Day-Year) – Required

(Apt #)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FORMER LAST NAME(S)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

–

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(State)

 

 

(Zip Code)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PHONE

 

 

 

 

 

 

 

 

–

 

 

 

 

 

 

 

 

 

 

 

–

 

 

 

 

 

 

 

 

 

 

Race/Ethnicity

1.

Native American

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Home/Cell)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2.

Asian/Paciic Islander

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3.

Black

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

E-MAIL ADDRESS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Optional)

4.

White

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5.

Hispanic

 

1.

Have you ever been convicted of any crime, excluding minor trafic violations?

YES

NO

2.

Have you ever been dismissed for cause from any position?

 

 

 

 

 

 

YES

NO

3.

Have you ever surrendered a professional certiicate, license, permit or other credential

YES

NO

 

(including, but not limited to, an education credential); had one revoked, suspended,

 

 

 

 

annulled, invalidated, rejected or denied for cause; or been the subject of any other

 

 

 

 

adverse or disciplinary credential action?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Pursuant to Connecticut General Statutes Section 10-221d, the State Board of Education must complete a criminal history records check on each applicant for an initial issuance or renewal of a certiicate, authorization or permit. Each applicant seeking an initial issuance or renewal of a certiicate, authorization or permit must also submit to a records check of the Department of Children and Families’ child abuse and neglect registry established pursuant to Connecticut General Statutes Section 17a-101k. In addition, the State Board of Education is required to submit periodically for a criminal history records check the database of all persons who hold any certiicate, authorization or permit.

NOTE: If you answer “YES” to any of the above questions, you must attach a signed statement of explanation. If there are multiple incidents within each question, you must list and explain each separately. Submit oficial copies of court or adminis- trative record(s), including disposition of each case.

Information on this application is subject to disclosure pursuant to the Freedom of Information Act.

PAGE 1

ED 185

PART II: COMPLETION OF REQUIRED FIRST AID COURSE

The irst aid course must have been completed within 3 years prior to the date of application. Please sign your irst aid card and attach: (1) a photocopy of both the front and back of the irst aid card, or (2) original certiicate of completion, to this application.

Name of course completed

Date of completion

PART III: COMPLETION OF REQUIRED CPR COURSE

Please sign your valid CPR card and attach: (1) a photocopy of both the front and back of the CPR card, or (2) original certiicate of completion, to this application.

Name of course completed

Date of completion

PART IV: HIGH SCHOOL INFORMATION

Please attach a copy of your high school diploma or oficial high school transcript to this application.

PART V: CONCUSSION AND HEAD INJURY TRAINING REQUIREMENT

Attach the original certiicate of completion of the concussion and head injury training requirement (Module 15) from the Connecticut Coaching Education Program (CCEP).

PART VI: COMPLETION OF REQUIRED COACHING COURSE

(For individuals NOT holding a valid Connecticut educator certiicate, or a standard or permanent certiicate)

Course completed at:

 

Date course completed:

 

(Name of college/university or board of education)

 

PART VII: RENEWAL OF FIVE-YEAR RENEWABLE COACHING PERMIT

Have you completed at least 15 clock hours of seminars, course work or workshops which provide

 

YES

information on safe and healthful coaching practices and understanding child and adolescent development

 

 

as approved by the State Department of Education?

 

 

NO

On or after July 1, 2010, through June 30, 2015, completion of the concussion and head injury training requirement (Module 15) from the Connecticut Coaching Education Program (CCEP).

After July 1, 2015, completion of the refresher course completed through the CCEP.

PART VIII: APPLICANT ATTESTATION

I certify that the information provided by me on this application and any accompanying documents contains no material misrepresentations, falsiications or omissions and that all of the information given by me is true, complete and accurate. I understand that all application and accompanying information may be veriied and that any material misrepresentation, falsiication or omission may result in the denial or revocation of my certiicate(s), permit(s) or authorization(s). I further certify that I have attained the age of at least 18 years.

ORIGINAL SIGNATURE OF APPLICANT

DATE:

Original Signature Must Be On Form Submitted

PAGE 2

ED 185 CONNECTICUT STATE DEPARTMENT OF EDUCATION

REV. 1/12

Bureau of Educator Standards and Certiication

 

C.G.S. 10-145

 

C.G.S. 10-145d

C.G.S. 10-149

C.G.S. 10-149b

Regs. 10-145d-423

P.O. Box 150471 – Room 243

Hartford, CT 06115-0471

www.ct.gov/sde

INSTRUCTIONS TO APPLICATION FOR

FIVE-YEAR RENEWABLE COACHING PERMIT

Listed below are the required documents which must be submitted to the Bureau of Educator Standards and Certiication to process your request for the issuance or renewal of a Five-Year Renewable Coaching Permit.

For the ISSUANCE of a Five-Year Renewable Coaching Permit you must complete and submit the following:

Applicant:

1. If you do NOT hold a valid Connecticut educator certiicate, or a standard or permanent certiicate, please com- plete sections a through g of the instructions below.

2. If you hold a valid Connecticut educator certiicate, or a standard or permanent certiicate, please complete sec- tions a, b, c, f and g of the instructions below.

Instructions:

a. Complete Parts I through VI and Part VIII of the application. (Applicants who hold a valid Connecticut educator certiicate, or a standard or permanent certiicate, need not complete Parts IV or VI).

b. Attach a photocopy of your valid Standard First Aid card, or original certiicate of completion. The Standard First Aid course must be completed within three years prior to the date of application. Please remember to sign your

Standard First Aid card prior to photocopying.

c. Attach a photocopy of your valid CPR card, or original certiicate of completion. Please remember to sign your

CPR card prior to photocopying.

d. Attach a photocopy of your high school diploma or its equivalent. An oficial high school transcript may be sub-

mitted in lieu of a copy of your diploma.

e. Oficial transcript/certiicate verifying the completion of an approved coaching course.

f. Attach the original certiicate of completion of the concussion and head injury training requirement (Module 15) from the Connecticut Coaching Education Program (CCEP).

g. Return completed application and attachments to the Bureau of Educator Standards and Certiication.

(continued)

Information on this application is subject to disclosure pursuant to the Freedom of Information Act.

For the RENEWAL of a Five-Year Renewable Coaching Permit:

Instructions:

a. Complete Parts I through III and Parts VII and VIII.

b. Attach a photocopy of your Standard First Aid card, or original certiicate of completion. The Standard First Aid course must be valid for the renewal date of the permit. Please remember to sign your Standard First Aid

card prior to photocopying.

c. Attach a photocopy of your CPR card, or original certiicate of completion, valid for the renewal date of the permit after course. Please remember to sign your CPR card prior to photocopying.

d. On or after July 1, 2010, through June 30, 2015, attach original certiicate of completion of the concussion and head injury training requirement (Module 15) from the Connecticut Coaching Education Program (CCEP). After July 1, 2015, attach oficial veriication of the refresher course completed through the CCEP.

e. Return completed application and attachments to the Bureau of Educator Standards and Certiication.

NOTE: Please do NOT submit veriication of completion of the required 15 clock hours of seminars, course work or workshops for the renewal of the Five-Year Renewable Coaching Permit with this application. Applicants selected for a random audit will be notiied in writing, and be required to submit veriication.

Please submit the application for renewal no sooner than six months prior to the expiration date of your current permit.

How to contact the Bureau of Educator Standards and Certiication:

E-mail:

teacher.cert@ct.gov

Website:

www.ct.gov/sde

FAX:

860-713-7017

24-hour Interactive Voice Response (IVR) for applicants.

PHONE:

860-713-6969

 

(To speak with a staff member, call the IVR weekdays, between 1-5 p.m.)
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Document Specifications

Fact Name Fact Details
Form Purpose The ED 185 form is used to apply for a five-year renewable coaching permit in Connecticut.
Governing Law The application process is governed by Connecticut General Statutes Sections 10-145, 10-145d, 10-149, and 10-149b.
Personal Information Applicants must provide personal information including name, address, Social Security number, and gender.
Criminal History Check Connecticut law mandates a criminal history records check for all applicants seeking initial issuance or renewal of the permit.
Child Abuse Registry Check Applicants must also undergo a records check of the Department of Children and Families’ child abuse and neglect registry.
First Aid Requirement A valid first aid certification completed within the last three years must be submitted with the application.
CPR Requirement Applicants are required to submit a valid CPR certification along with their application.
Concussion Training Completion of a concussion and head injury training course is mandatory for applicants, with specific modules outlined.
High School Diploma A copy of the applicant's high school diploma or official transcript is required as part of the application.
Attestation Applicants must certify that all information provided is accurate and complete, acknowledging the potential for verification.
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