Pottsboro Youth Association

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Volunteer Application

COACH INFORMATION

* First Name:

Middle Name:

* Last Name:

Previous or Maiden Name:

Street:

City:

State:

Zip Code:

Email:

Phone:

Alt Phone:

* Birthdate:

Volunteer Position:

Previous states of residence past 5 year:

Have you ever been convicted of a felony?:

If yes please explain:

Have you ever been convicted of any crime involving a minor?:

Have you ever been refused participation in any youth program?:

If yes please explain.:

Social Security Number:

WAIVER INFORMATION

As a pre-condition to serving as a Pottsboro Youth Association (PYA) Youth Coach/Volunteer, I give permission to PYA, including one of its associates, to conduct criminal background screening on me, which will include a review of sex offender registries, child abuse, and criminal history records. I hereby release and hold harmless from liability the local PYA, the officers, employees, agents, volunteers thereof, and any other person or organization that may provide such information in accordance with the laws of the United States. I hereby swear and attest that all information provided on this application is true and complete to the fullest extent of my knowledge. If I am accepted as a volunteer, PYA may end the relationship immediately if I have made any false statements or material misrepresentations, written or verbal. I understand and agree that, if appointed, my position is conditional upon the league receiving no inappropriate information on my background. I agree to treat the responsibility of coaching kids with the utmost respect and will be held accountable for any derogatory actions or comments.

I/we agree with the above *

* indicates required fields

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Volunteer Application