Westfield Youth Soccer Association, Inc
POBox 346
Westfield IN 46074
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FIRST NAME & MI         LAST NAME
_______________________ 
SOCIAL SECURITY NUMBER     GENDER: M ___ F ___           

DATE OF BIRTH __________________________

_______________________ _____________ _____ ________
ADDRESS                         CITY               STATE ZIP CODE
___________________ ____________________
HOME PHONE             BUSINESS PHONE
__________________________ _________ ________________
DRIVER'S LICENSE NUMBER STATE       EXPIRATION

Background in work with youth: 

Position ____________________ Year(s) __________

Experience in youth soccer: 

Position ____________________ Year(s) __________

Experience in soccer: 

Position ____________________ Year(s) __________

Previous residence(s) for last 5 yrs: City _______________________ State __________
(Use back of form if necessary)

Have you ever been convicted of a crime of violence?
If yes, please explain: (use back of form if necessary)




Have you ever been convicted of a crime against a person?
If yes, please explain: (use back of form if necessary)


I understand that:
1. It is the intent of Westfield Youth Soccer Association to deny certification to any person who has been convicted of a crime of violence or of a crime against a person.
2. In applying for a Westfield Youth Soccer Association position, the information which I have furnished on this form is subject to verification, which may include a criminal history check.
3. This disclosure statement must be updated at least every two (2) years.

Signature ___________________________ Date ______________

Printed Name __________________________