South Metro Youth Athletic Association Coach’s Application
2011 Season

I. Personal Data (* indicates Required Field)

* Enter you Legal First Name:		

* Enter you Legal Last Name:		

* Street Address:		

* City:		* State		* Zip		

* Social Security Number:		* Date of Birth:		

* Home Phone:		 Mobile Phone:		

 Work Phone:		Employer:		

* E-mail(s):		

Child’s Name(s) & Date of Birth:				

* Select One:	Football	Cheerleading	

* 1st Choice Position:		ß Head Coach or Assistant	

* 1st Choice Division:			
	
* 2nd Choice Position:		ß Head Coach or Assistant	

* 2nd Choice Division:			

II. Experience

Please list all experience as a Youth Head Coach: 
(Yr, Level, Organization, League) 		

Please list all experience as a Youth Assistant Coach: 
(Yr, Level, Organization, League) 		

Please list other coaching experience: 	

Please check if you have a valid certificaton for:	CPR?		First Aid?		NYSCA?		

* Have you ever been convicted of a felony?	Yes?		No?		
* Are you subject to any civil restraining order or any 
   type of civil action relating to child or domestic abuse?	Yes?		No?		
* If Yes, Please Provide Dates, Charges, and Explanation? (attach another sheet if necessary)	

	

* Are you willing to particpate as a volunteer at fundraisers, weigh-ins, and or bowl games?		
I understand that my volunteer position with SMYAA is contingent upon mu truthful completion and SMYAA’s review of this form.  I authorize and understand that SMYAA may obtain a criminal history report that is only visible to the SMYAA Presdident.  I undertsnad that I may be immediately discharged for any misrepresentation or material ommission on this form. I understand that any pending arresst or closed arrest is not an automatic bar to consideration of my application, but it is the intent of SMYAA to deny a position to any person who has been convicted of sexual abuse, physical abuse, or epxlotation of a minor.
* check this box if you read and agree to the previous statement		

(Signature)		(Date)