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Disclosure
All
information will be maintained by SAYSO in strict confidentiality.
A. Last name:
______________________________
First name:
______________________________
Middle name:
____________________________
Street:
__________________________________
City:
___________________________________
Zip:
____________________________________
B. Have you lived at other
addresses during the previous 10 year? ( ) No ( ) Yes
(If "Yes", please list the addresses and dates of residence on the back of this
page.)
C. Home phone: ____________________________
Work phone:
____________________________
Cell phone:
_____________________________
Pager:
_________________________________
Fax:
__________________________________
D. Gender (yours): (
) Male ( ) Female
E.
Date of Birth (MM/DD/YY): ____________
F. City, State, and Country of
Birth: __________________________________
G. Email address: ____________________
H. Do you agree to abide by the SAYSO Constitution, Bylaws, Policies,
and Operating Rules? ( ) No ( ) Yes
I. Do you use illegal drugs? ( ) No ( ) Yes
J. Have you ever been convicted of a crime of violence? ( ) No
( ) Yes (If "Yes", please explain on the back of this page.)
K. Have you ever been convicted of a crime against a person? ( )
No ( ) Yes (If "Yes", please explain on the back of this
page.)
L. Other than red cards received at games, have you ever been
suspended from a coaching position by a club, league, district, association,
organization, or employer? ( ) No ( ) Yes (If
"Yes", please explain on the back of this page.)
M. Is there any fact or circumstance involving you, your background,
or those that you most closely associate with that would
call into question SAYSO's decision to entrust you with the supervision, guidance, and care of young people?
( ) No ( ) Yes (If "Yes", please explain on the back of
this page.)
N. Have you ever gone by a different name, alias, or AKA? Have you
ever legally changed your name? ( ) No ( ) Yes (If
"Yes", please explain on the back of this page.)
O. Social Security Number: ___________________________________________
(optional)
P. Driver's license: State:_____ Number ____________________
Expiration date _____ (required)
By signing this application, I understand, agree, certify, and consent...
(i)
... that all
information given by me in this Disclosure/Application and on any Statements of
Interest is true and correct to the best of my knowledge; and, that false or
misleading statements made by me or consequential omissions of any kind in the
application process are significant cause for my not being accepted as SAYSO
employee/volunteer or for my dismissal no matter when discovered, and...
(ii) ... to SAYSO's policy of deny an
application from any person who has been convicted of a crime of violence or a
crime against a person, who is a user of illegal drugs, or who might call
SAYSO's decision to approve the application into question, and...
(iii) ... to SAYSO verifying the information on this
application, including getting a check of my background and other history; and,
I authorize employers, organizations, and individuals to give SAYSO any and all
information regarding my employments, volunteering, character, fitness and
qualifications (including opinions) that they have about me, and....
(iv) ... to keep SAYSO informed as to any changes in
the answers to these questions that may occur, and...
(v) ...to SAYSO's request to update of the information
on this application at least every two years, and...
(vi) ...to maintain at least the minimum amount of
insurance as required by the State of California per the State Vehicle Code; and
to notify SAYSO in writing if at any time I do not have such coverage and I am
asked to use my personal or non-owned vehicle on behalf of SAYSO; and, to
disallow any person who does not have authorization and/or insurance to drive my
vehicle on SAYSO related business, and...
(vii)
... that
I HEREBY WAIVE, RELEASE AND
DISCHARGE SAYSO, all employers, organizations and individuals, and any other
persons or entities from liability for all damages and losses of whatever kind
or nature, except liability for willful or intentional acts or punitive damages,
that may result from compliance or attempts to comply with this authorization.
Signature: ____________________________ Date: ____________
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Coaching
Application,