All individuals who will serve as coaches, assistant coaches, trainers, or will have direct contact with LYSA youth participants in their LYSA-required volunteer roles must fill out a background check form.? Forms should be mailed or faxed to LYSA.
LYSA COACHING APPLICATION & BACKGROUND CHECK
Youth Leader Request			Do NOT send this form to Frankfort.? Only forms submitted through LYSA are acceptable.
Pursuant to KRS 17.160
Organization:______________	Lexington Youth Soccer Association (LYSA)
Address:	3805 Hopemont Drive, Lexington, KY 40514
Contact Person:	Nina O?Leary
Phone Number:	Office: (859) 223-5632?? Fax: (859) 223-8643
Tax Exempt Number:	D14844
Background Checks are performed by: Administrative Office of the Courts Pretrial Services 100 Millcreek Park Frankfort, Kentucky 40601		The Background Check Process The records requested will be returned to the mailing address (LYSA) in a postage paid self-addressed return envelope to LYSA.? A separate addressed envelope for each person on which a Background Check has been requested is required and is provided by LYSA in order that individuals get to see the results of their Background Check.? If you have any questions regarding the results of your Background Check, especially accuracy, please contact Pretrial Services at (800) 928-6381.
PLEASE PRINT OR TYPE INFORMATION CLEARLY: ???????????????? Today?s Date: ____________________ Social Security Number:????????? _______________________??????? Date of Birth: ____________________ Driver?s License Number:??????? ______________________________________________ Full Name:?????????????????????????????? ______________________________________________ Maiden or Alias Name:??????????? ______________________________________________ Street Address/ P.O. Box:??????? ______________________________________________________ City, State, Zip Code:?? ______________________________________________________
League:? q Recreational? q Lexington FC?????????? Age Group: Under-______???????? Team Type:? ?q Mixed??? q Girls Team Name: ?__________________________ Home e-mail: __________________________???????????????? Work e-mail: _______________________ Home phone: __________________________???????????????? Work phone: _______________________ What state did you live in for the last 6 months??? _________________________________ List in chronological order with dates, other states that you have lived in over the last 20 years. __________________________________________________________________________________ Have you ever been removed or restricted from youth coaching in any sport? . . . ??? q? Yes or q? No Have you ever been convicted of a violent crime?? . . . . . . . . . . . . . . . . . . . . . . . .? q? Yes or q? No Do you have any convictions involving drugs?? . . . . . . . . . . . . . . . . . . . . . . . . . . . q? Yes or q? No Do you have any convictions that involve physical or sexual abuse . . . . . . . . . . .?? q? Yes or q? No Do you have any convictions as a sex offender?? . . . . . . . . . . . . . . . . . . . . . . . . . q? Yes or q? No I pledge that the information that I am providing is true and accurate, and if false, I understand that I may not be able to serve as a coach. Signed____________________________________________________________????????????????? Revised 06/10/06 ??????????????? (LYSA reserves the right to determine the suitability of any individual for coaching)