Please print clearly and complete this form in full.  Return to your local association Risk Manager.

EMPLOYMENT/VOLUNTEER DISCLOSURE STATEMENT

_____________________________  ___________________________  _________________________

FIRST NAME                                          MIDDLE INITIAL     LAST NAME                                                         SOCIAL SECURITY NUMBER

_____________________________  ___________________________  ______________   ________

STREET ADDRESS                                                    CITY                                                                    STATE                                    ZIP CODE           

_____________________________  ___________________________  _____________ 

HOME PHONE                                                         BUSINESS PHONE                                            DATE OF BIRTH             

_____________________________  ___________________________  GENDER      □ M     □ F

COACHING LICENSE                                            REFEREE GRADE              

_____________________________  ___________________________  ____________________             DRIVER'S LICENSE NO.                                         STATE                                                                   EXPIRATION

_____________________________       Position  (Check all that apply)

ASSOCIATION                                                                                     □ Coach                 □ Administrator □ Manager

                                                                                                □ Referee              □ Volunteer                □ ________________

PLEASE COMPLETE IN FULL:

1.  Previous residence(s) (for last 5 years)                    City ___________________________   State_____________________    

2.  Have you ever been convicted of a crime of violence?              YES                        NO              

                If yes, please explain: (Use the back of form if necessary)                                     

3.  Have you ever been convicted of a crime against a person?   YES                        NO               

                 If yes, please explain: (Use the back of form if necessary)                                     

I understand that:

a.     It is the intent of South Dakota State Soccer Association and USYSA to deny certification to any person who has been convicted of a crime of violence or of a crime against a person.

b.     In applying for a SDSSA/USYSA position, the information which I have furnished on this form is subject to verification, which may include a criminal history check.

c.     This disclosure statement must be updated as required by South Dakota State Soccer Association. 

    ____________________________  ________________________________  ____________                                            

Signature                                                                Printed Name                                                                            Date                        

    FORM SDSSARM-2003