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

EMPLOYMENT/VOLUNTEER DISCLOSURE STATEMENT

Youth Form (Under 18 years of age)

_____________________________  ___________________________ 

FIRST NAME                             MIDDLE INITIAL      LAST NAME                                    

_____________________________  ___________________________  ______________   ________

STREET ADDRESS                                                      CITY                                                                    STATE                                      ZIP CODE           

_____________________________  ___________________________  _____________ 

HOME PHONE                                                                 BUSINESS PHONE                                                     DATE OF BIRTH             

_____________________________  ___________________________ GENDER    □ M     □ F

COACHING LICENSE                                                    REFEREE GRADE              

_____________________________  ___________________________   ____________________           

DRIVER'S LICENSE NO. (If Applicable)                   STATE                                                                             EXPIRATION

_____________________________            Position (Check all that apply)

ASSOCIATION                                                                     □ Coach                 □ 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 is kept in confidence because I am under the age of 18.  If it is found that I have given false or incomplete information, I will be subject to immediate dismissal.

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

    ____________________________  ________________________________  ____________                                            

Signature                         Printed Name                               Date                        

    ____________________________  ________________________________  ____________                                             

     Parent/Guardian Signature         Printed Name                               Date                        

 FORM SDSSA-RM-YOUTH-2003