RUSH-HENRIETTA
TRAVEL SOCCER
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TRAVEL SOCCER
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DISCLOSURE STATEMENT Please circle each appropriate selection: This application is for a: 1. New Pass 2. Renewal Pass 3. Replacement for a Lost Pass for a:1. Certified Referee 2. Coach 3. Asst Coach 4. Manager 5. Administrator 6. Volunteer District : 1. Buffalo 2. Rochester 3. Syracuse 4. Binghamton 5. Southern Tier 6. Twin TiersProgram (if applicable): 1. Certified Referee 2. TOPSoccer 3. ODP Forward this form to your club or league/ program official to be checked and then mailed to the NYSWYSA State Office Club/League/Program Official: ___________________________________________________________________________PRINTED NAME DATE Club/League/Program Name & Number: ___________________________________________________________________Club/League/Program Address: ___________________________________________________________________________ٱ Check this box and sign below ONLY IF you want NYSWYSA to conduct a background search for the Volunteer orAdministrator listed on this form Club/League/Program Official Signature: ___________________________________________________________________ REVISED August 26, 2003 BACKGROUND INVESTIGATION CONSENT PLEASE PRINT CLEARLYI, ___________________________________________________, hereby authorize New York State West Youth Soccer Association and/or itsagents to make an independent investigation of my background, criminal or police records, including those maintained by both public and private organizations and all public records for the purpose of confirming the information provided on this form. I release NYSWYSA and/or its agents and any person or entity, which provides information pursuant to this authorization, from any and all liabilities, claims, or law suits in regards to the information obtained from any and all of the above referenced sources used. The following is my true and complete legal name, and all information is true and correct to the best of my knowledge: ________________________________________________________ Gender: M or F ___________________FULL NAME (LAST, FIRST, MI) SOCIAL SECURITY # _______________________________________________________________________________________________________________ MAIDEN NAME OR ANY OTHER NAMES USED _______________________________________________________________________________________________________________ PRESENT ADDRESS CITY STATE ZIP CODE COUNTY HOW LONG? _________________________ ________________________ _____________________ HOME PHONE BUSINESS PHONE DATE OF BIRTH _______________________________________________________________________________________________________________ FORMER ADDRESS CITY STATE ZIP CODE COUNTY HOW LONG? _________________________ ___________________________ _______________________ DRIVER’S LICENSE NUMBER STATE ISSUED EXPIRATION DATE ________________________________ ________________________________ _______________________________ COACHING LICENSE AND # REFEREE GRADE AND USSF ID # REFEREE DISTRICT 1. Have you ever been convicted of a crime of violence? YES NO If YES, please explain (use back of form if necessary) 2. Have you ever been convicted of a crime against a person? YES NO If YES, please explain (use back of form if necessary) 3. Have you ever had your license suspended/revoked for driving under the influence of alcohol? If YES, please explain (use back of form) YES NO I UNDERSTAND THAT it is the intent of the New York State West Youth Soccer Association to deny certification to any person who has been convicted of a crime of violence or a crime against a person or who provides false information on this disclosure statement. _________________________________ _______________________________________ ________________ SIGNATURE FULL NAME (PRINTED ) DATE Note: For an applicant under the age of 18, a parent or legal guardian must sign this form |
Last modified: 8/20/08 Rush Henrietta Travel Soccer Club, P.O. Box 460, Henrietta, New York 14467 |
