Special Olympics Michigan Poly Hockey Team Evaluation Questionnaire
In order to make team registration easier at the event, we ask that you fill out ONE of these forms PER TEAM. Please note that we ask for the number of coaches and chaperones so they can receive the appropriate ribbon identification. This form should be completed and turned in with your registration materials. Thank you for your assistance.
Area
Area Director Name (First, Last)
Your answer
School Name (if applicable)
Your answer
Please Select Team Type
Head Coach Name (First, Last)
Your answer
Phone Number
Your answer
Email Address
Your answer
Years of Special Olympics coaching experience
Your answer
Years coaching this team
Your answer
Assistant Coach Name (First, Last)
Your answer
Assistant Coach Email Address
Your answer
Team Name
Your answer
Last Year's Team Name
Your answer
I will be attending the following (select all that apply):
Required
Are the majority of this year's players the same as last year?
Required
List any significant changes in your team this year:
Your answer
Based on a 10-division tournament, in what division would you place this team this year?
Your answer
It is a state requirement that you turn in the results of three game scores by Oct. 24. These games should be with other Special Olympics teams. If you have problems answering the above questions, please call the state office for further information. Please check if you acknowledge this requirement.
Required
Meal Tickets Needed
Medical:
Your answer
Coach:
Your answer
Chaperone:
Your answer
Guest:
Your answer
Athlete's:
Your answer
Managers/Cheerleaders:
Your answer
Total Meal Tickets Needed
Your answer
USING THE DIRECTIONS FOR EACH SKILL, EVALUATE EACH ATHLETE INDIVIDUALLY FOR EACH OF THE 4 LISTED SKILLS.
TAKE THE THREE HIGHEST SCORES AND RECORD THEM BELOW
Event #1: Shoot around the goal (For event instructions please hover mouse over the image, or visit http://somi.org/sports/rules/POLY%20HOCKEY%20RULES.pdf)
Athlete takes one shot from five different spots around the goal. These spots are located at the end points of five 6-meter rays, which start from a common point. Each ray is drawn such that it creates a 30 degree angle with the goal line or with a previously-drawn ray. An athlete has a 30 second time limit to shoot all the pucks. One puck shall be at each spot before the athlete starts. Scoring: Each puck that completely crosses the goal line into the goal is worth five points. The score is the total of the five shots with 25 points maximum.
TEAM SKILL SCORE OF: 0 - 15 = 1, 16 - 31 = 2, 32 - 47 = 3, 48 - 63 = 4, 64 - 75 = 5
Total Score:
Event #2 - Pass
Athlete makes five passes from behind a line. Athlete tries to pass the puck between two cones 4 feet apart that are placed 32 feet from the passing line. Each time the puck passes completely across the line between the two cones, the athlete shall be awarded five points. If the puck hits the cone, but still passes through the cones, the athlete shall be awarded three points. The athlete's total score is the sum of the five passes with 25 points maximum.
TEAM SKILL SCORE OF: 0 - 15 = 1, 16 - 31 = 2, 32 - 47 = 3, 48 - 63 = 4, 64 - 75 = 5
Total Score:
Event #3 - Stick Handling
Athlete stick handles the puck from a starting line through a course defined by cones and shoots the puck at the goal. The distance from the start line to goal line shall be 21 meters. The cones shall be placed in a straight line at intervals of 3 meters. The clock stops when the puck passes the goal line. Scoring: The time spent stick handling is subtracted from 60. If any cones are missed, one point is  subtracted for each miss. Five bonus points are given if the athlete scores a goal.
TEAM SKILL SCORE OF: 0 - 36 = 1, 27 - 73 = 2, 74 - 110 = 3, 111 - 146 = 4, 147 - 180 = 5
Total Score:
Event #4 - Shoot For Accuracy
Athlete takes five shots from behind a line that is five meters from and directly in front of, the goal. Six sections are defined within the goal by rope or tape as shown in the diagram. The vertical rope or tape is hung 45 cm (18") in from each goal post. The horizontal rope or tape is strung 30 cm (12") above the floor. Scoring: The goal is divided into point sections as follows:  -5 points for any shot entering the goal in either of the upper corners.  -3 points for any shot entering the goal in either of the lower corners.  -2 points for any shot entering the goal in the upper middle section.  -1 point for any shot entering the goal in the lower middle section.  -0 points for any shot not entering the goal
TEAM SKILL SCORE OF: 0 - 15 = 1, 16 - 31 = 2, 32 - 47 = 3, 48 - 63 = 4, 64 - 75 = 5
Total Score:
TEAMS’ GENERAL POLY HOCKEY KNOWLEDGE
FINAL SCORE
Add the total score from each of the 4 events, plus the rating for the teams general knowledge. Maximum score of 30
Your answer
Please write below any pertinent comments that may not be covered above that would help evaluate the overall team ability.
Your answer
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