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First Name & Initial
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Last Name
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Social Security Number
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Address (No PO Box Address)
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Town
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State
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Zip Code
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( )
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( )
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Home Phone
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Business Phone
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Date of Birth
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Drivers License Number
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State
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Expiration
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1. Background in work with youth
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Position___________________________
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Year(s)____________
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2. Experience in soccer
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Position___________________________
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Year(s)____________
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3. Experience in youth soccer
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Position___________________________
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Year(s)____________
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4. Previous residence(s)
(for last 5 years)
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City______________________________
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State______________
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5. Have you ever been convicted of a crime or disorderly person offense? If yes, please explain (Use back of form if necessary)
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ÿYes ÿNo
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6. Have you ever been convicted of a crime against a person? If yes please explain (Use back of form if necessary)
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ÿYes ÿNo
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I understand that:
a. It is the intent of New Jersey Youth Soccer to deny certification to any person who has been convicted of a crime of violence or a crime against a person.
b. This disclosure statement must be updated at least every year.
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________________________
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________________________
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________________________
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Signature
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Printed Name
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Date
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THIS FORM IS TO BE HANDED IN TO YOUR CLUB’S KIDSAFE COORDINATOR
Our Club’s KidSafe Coordinator shall store this completed form in a secure environment.
The form will not be sent to New Jersey Youth Soccer.
