Florida Youth Soccer Coach/Volunteer Application & Risk Management Disclosure

I understand that by submission on this application to register with the FYSA affiliate below, I will be subjected to periodic background checks, at a schedule set by FYSA, using whatever services or methods that the FYSA deems appropriate. The results of this background check may be used to deny me the right to participate with any FYSA affiliated organization or program. My signature below authorizes FYSA to periodically run a legally sensitive criminal history check at any time in the future based on the information I have provided on this form. I also understand that should FYSA discover criminal activity that I have not disclosed to FYSA either on this form or by other means, that my status as a coach can be revoked. This form must be completed entirely in order to be accepted, failure to properly and completely disclose a past criminal history will result in charges of Falsification of Documentation as defined under FYSA’s Code of Ethics and/or Rule 505.4
Have you ever been convicted of, pled no contest to and had adjudication withheld, or entered a pre-trail diversionary program regarding any of the following: (1) any felony, (2) any crime against another person, (3) any crime involving moral turpitude, (4) any crime of violence. Yes ____ No ____ If you answered yes to the above, please attach to this form a statement of disclosure explaining all such situations which caused you to answer yes to the above question, including the details of the crime, that date of conviction and penalty imposed (if any) along with any mitigating factors which you would like the FYSA’s Risk Management committee to consider Have you ever been a Defendant in a civil action for an intentional tort? Yes _____ No _____ If yes please include the nature of the tort (whether a battery, assault, etc., ) and how the action was resolve

Incidents that FYSA should know about__________________________________________________________________
_________________________________________________________________________________________________
                                                            Continue on back or attach separate sheet.

NOTE: In the future the applicant shall resubmit this form as a result of any incident as described above. This form must be resubmitted to FYSA thru the affiliate, not later than the submission for registration for the following seasonal year if there are any changes to the Risk Management Disclosures.

Signature: ____________________________________________ Date: _______________________
 

Please Check status applied for ____ Coach ____ Volunteer VPN _________________
 

Print Full Legal Name _____________________________________________________________

Address:___________________________________________________________________________

City: ____________________ Zip Code: ______

Home Phone _____________________ Work Phone _________________ Mobile _____________________

Date of Birth ____________ Gender ____ Social Security Number __________________________

E-mail Address _____________________________________________________________________

Affiliate/Team Information: In submitting this form to FYSA, the affiliate is certifying that the actual identity of the coach/volunteer has been confirmed by the affiliate.
The person listed above produced ___________________________________ as identification.
Signature of Registrar _____________________________________ Date ____________________

District Code ___ C2 ___ Affiliate Code ___ TSS ___ License _________________________

Please also roster the above named coach to the additional teams listed below:
____________________________________________________________________________________

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