Iowa State Youth Soccer Association
Employment/Volunteer Disclosure Form

___________________
Last Name 		_____________________
First Name & Middle Initial 		_____________________
Social Security Number
___________________
Address 		_____________________
City 		_____________________
State and Zip Code
___________________
Home Phone 		_____________________
Business or Daytime Phone
Gender _____M ______F
___________________
Driver's License # 		_____________________
State Issued & Expiration 		_____________________
Date of Birth
___________________
Coaching License 		_____________________
Referee Grade

  1. Background in work with youth.....Position_________________Year(s)___
  2. Experience in soccer......Position_________________________ Year(s)___
  3. Experience in youth soccer...........Position__________________Year(s)___
  4. Previous residence(s) for the past 5 years...City_______________State____
    (Use the back of form, if necessary)
  5. Have you ever been convicted of a violent crime?......................Yes__No__
    (If yes, please explain. Use a separate sheet, if necessary.)
  6. Have you ever been convicted of a crime against a person?........Yes__No__
    (If yes, please explain. Use a separate sheet, if necessary.)

I understand that:

a. It is the intent of Iowa State Youth Soccer Associations to deny certification to any person who has been convicted of a crime of violence or a crime against a person.

b. Falsification of information on this disclosure statement may be grounds to deny certification.

c. This disclosure statement must be updated at least every two years.

d. In applying for a Iowa State Youth Soccer Association position, I authorize the release of records pertaining to any criminal and domestic abuse history. This authorization is given in connection with a background investigation which may be conducted relative to my application. Any information obtained by a background check will be considered in determining my suitability for the positioin for which I am applying. In the event my application is disapproved on the basis of a backgound check, the sources of confidential information cannot be revealed to me. Further, I agree to indemnify and hold harmless the person to whom this request is presented and his/her agents and Iowa State Youth Soccer Association, from and against all claims, damages, losses and expenses, including reasonable attorney's fees, arising out of or by reason of complying with this request.
___________________
Signature 		____________________
Printed Name 		___________________
Date
Mail form to: Iowa Soccer Association
524 Merle Hay Tower
Des Moines, IA 50310
515-252-6363 or 800-FUN-IOWA
515-252-7676 (Fax)




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