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-trial 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 questions, including the details of the crime, the 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 resolved.

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                                               

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