MIME-Version: 1.0 Content-Location: file:///C:/DD28BA36/BackgroundCheckFormFIX-06-10-06.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="us-ascii" All individuals who will serve as coaches, assistant coaches, traine= rs, or will have direct contact with LYSA youth participan

 

All individuals who will serve as coaches, assistant coaches, trainers, or wi= ll 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 thro= ugh LYSA are acceptable.

Pu= rsuant to KRS 17.160

Organization:&= nbsp;          

Lexington Youth Soccer Association (LYSA)<= /span>

Address:

3805 Hopem= ont Drive, Lexington, KY = 40514

Contact Person:

Nina O’Le= ary

Phone Number:

Office: (859) 223-5632   Fax: (859) 223-8643

Tax Exempt Number:

D14844

Background Checks are performed by:<= /span>

Admi= nistrative 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 pos= tage paid self-addressed return envelope to LYSA.  A separate addressed envelope fo= r 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 ha= ve any questions regarding the results of your Background Check, especially accuracy, please contact Pretrial Services at = (800) 928-6381.

PLEASE PRINT OR TYPE INFORMATION CL= EARLY:            &nbs= p;     Today's Date: ____________________

Social Security Number:        = ;  _______________________        Date of Birth: ____________________

Driver's License Number:        = ; ______________________________________________=

Full Name:        = ;            &n= bsp;          _________= _____________________________________

Maiden or Alias Name:        = ;    ______________________________________________

Street Address/ P.O. Box:        ______________________________________________________=

City, State, Zip Code:   ___________________________= ___________________________

League:  __Recreational  __ Lexington FC           Age Group: Under-______  &n= bsp;      Team Type:  __ Mixed    __ Girls<= /span>

Team Name:  __________________________

Home e-mail: __________________________=         = ;         Work e-mail: _______________________

Home phone: __________________________=         = ;         Work phone: _______________________

What state did you live in f= or 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? . . .     __  Yes or __  No

Have you ever been convicted= of a violent crime?  . . . . . . = . . . . . . . . . . . . . . . . . .  __  Yes or __  No

Do you have any convictions involving drugs?  . . . . . = . . . . . . . . . . . . . . . . . . . . . . __  Yes or __  No

Do you have any convictions = that involve physical or sexual abuse . . . . . . . . . . = .   __  Yes or __  No

Do you have any convictions = as a sex offender?  . . . . . . .= . . . . . . . . . . . . . . . . . . __  Yes or __  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______________________= ______________________________________       &nbs= p;          Revise= d 06/10/06

            =     (LYSA reserves the right to determine the suitability of any individual for coaching)