YOUTH SPORTS COACHES APPLICATION NAME _____________________________________ HOME PHONE _____________________________ WORK PHONE ______________________________ ADDRESS __________________________________ CITY _____________________________________ ZIP _____________________________________ AGE _____________________________________ BIRTH DATE ______________________________ SOCIAL SECURITY NUMBER _________________________ DRIVER’S LICENSE # _________________________ _____HEAD COACH _____ASSISTANT Current Employer _______________________________ Address ________________________________________ SPORT _________________________ DIVISION/AGE GROUP _________________________ E-mail Address _________________________ FAX _________________________ Closest Public School _________________________ Voluntary Comments or Concerns: __________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________ Have you ever been convicted of any violations of federal, state, local or military law statute? ___Yes ___No If yes, explain._________________________________________________ ________________________________________________________ ________________________________________________________ ___________________________________________________ Please summarize your previous coaching experience (Peoria or other). ________________________________________________________ ________________________________________________________ ________________________________________ List any other experience you have had with voluntary or youth organizations. _______________________________________________________ _______________________________________________________ ____________________________ Personal References: 1. ________________________________________ Phone ______________________________ 2. ________________________________________ Phone ______________________________ By signing this application, I certify that all information on this form is true to the best of my knowledge. I also authorize the City of Peoria Community Services Department to make all necessary and appropriate investigations allowable by law. It is my responsibility to keep the Community Services Department advised of any changes in address, or phone numbers. Signature ________________________________________ Date ________________________ FOR OFFICE USE ONLY Application Received ______ Finger Print Status ______ NYSCA Cert. ______