Please fill out the form completely, all fields are required.

     

    First Name:    Last Name:

    Have you used any other name(s) or variations of your name? If so, please list:

    Current Address

    Email:

    Address:

    City: State: Zip:

     

    Previous Address
    (If you have lived at your current address for less than 5 years, please enter any additional addresses over the last 5 years.)

    Date of Birth:  Month: Day: Year:

    Gender: MaleFemale

    Phone Number:

    Occupation:

    Social Security Number:

    Driver License Number: State Issued:

    Legal:

    Have you ever been convicted of a criminal offense? (excluding minor traffic violations)

    NoYes

    Engaged in or been accused of any act of child molestation, exploitation, or abuse?

    NoYes

    If the answer to any of these questions is "yes," please explain in detail.

    I hereby authorize, without reservation, any law enforcement agency, administrator, state or federal agency, or information service bureau, to furnish any and all background information requested. I also agree that a fax or photocopy of this authorization shall be as valid as this original electronic copy.

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    Personal References:
    These must be people you have been acquainted with for at least the last 3 years, no relatives. *Coaches, please include at least one reference familiar with your coaching.

     

    1. Name:

    Phone:

    Email:

     

    2. Name:

    Phone:

    Email:

    Applicants Statement:

    The information contained in this application is correct to the best of my knowledge. I authorize any references listed in this application to give you any information they may have regarding my character and ability to work with youth and young adults and/or coach them. I release all such references from liability for any damage that may result from furnishing such evaluations to you, and I waive any right that I may have to inspect references provided on my behalf.

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