YOUTH SPORTS LEAGUE APPLICATION * REQUIRED * Metro Parks Tacoma and Boys & Girls Clubs of South Puget Sound 4702 South 19th Street Tacoma WA 98405
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1 YOUTH SPORTS LEAGUE APPLICATION * REQUIRED * Metro Parks Tacoma and Boys & Girls Clubs of South Puget Sound 4702 South 19th Street Tacoma WA CO-ED Basketball K-1 st Grade 2-3 rd Grade Girls Basketball 4 th /5 th Grade 6-8 th Grade 2Boys Basketball 4 th Grade 5 th Grade 6 th Grade 7-8 th Grade Districts See map in rules. Main Office Peoples Center Portland Ave Star Center Center at Norpoint Team Name Head Coach Address City Zip Code Home Phone Work Phone Cell Phone ** will be a main contact between coaches and MPT staff. I need equipment provided by MPT. (Please Circle) Yes No SCHEDULING CONFLICT REQUEST As per league rules: coaches are allowed 2 conflict requests, but are only guaranteed one. A conflict not reported to the league office at the time of the league application is submitted will require a $50 rescheduling fee. CONFLICTS Reason for conflict I accept full responsibility for all actions of my team and agree to fully abide by the rules outlined in appropriate Metro Parks Tacoma rule books and national organization rule books. I am the singular spokesman for my team (in my absence my assistant coach will be the official team spokesman), except for individual appeals for disciplinary actions. Upon any change in a coaching position, I agree to notify Metro Parks Tacoma Athletics Division immediately in writing of the change. The head coach and all assistant coaches are registered volunteers and have completed the MPT Coaches Training program. Head Coach Signature and Date Amount Paid: Date Paid: Staff Signature:
2 Assistant Coach Application Head Coach Name Assistant Coach Name Address City Zip Code Home Phone Work Phone Cell Phone ** will be a main contact between coaches and MPT staff. I accept full responsibility for all actions of my team and agree to fully abide by the rules outlined in appropriate Metro Parks Tacoma rule books and national organization rule books. I am the singular spokesman for my team (in the absence of my head coach), except for individual appeals for disciplinary actions. Upon any change in a coaching position, I agree to notify Metro Parks Tacoma Athletics Division immediately in writing of the change. The head coach and all assistant coaches are registered volunteers and will complete the MPT Coaches Training program. Assistant Coach Signature and Date
3 VOLUNTEER Background Consent/Release Form To be completed by supervisor and provided to volunteer: Department: Supervisor Name: Applicant s Legal Name (printed) Social Security Number Date of Birth Applicant s Address City State Zip I,, authorize and give consent for the above named organization to obtain information regarding myself. This includes the following: Local & National Criminal background records/information Sex Offender Registry Checks Addresses Social Security Verification I the undersigned, authorize this information to be obtained either in writing or via telephone in connection with my application. Any person, firm or organization providing information or records in accordance with this authorization is released from any and all claims of liability for compliance. Such information will be held in confidence in accordance with the organization s guidelines. I HAVE COMPLETED A DISCLOSURE STATEMENT (initial) I HAVE PRESENTED A VALID PHOTO IDENTIFICATION (initial) Print Name: Date: Signature:
4 Metro Parks Tacoma DISCLOSURE STATEMENT AND AUTHORIZATION TO COMPLETE BACKGROUND CHECK Pursuant to the requirements of RCW , we must ask you to complete the following disclosure statement. This information will be kept confidential. Have you ever been convicted of any of the following crimes against children or other persons: Yes No Aggravated murder First or second degree kidnapping First degree arson First, second or third degree assault First degree burglary First, second or third degree rape Indecent liberties First, second or third degree rape of a child Incest First or second degree robbery Vehicular homicide First or second degree manslaughter Unlawful imprisonment First or second degree extortion Simple assault First or second degree criminal mistreatment Sexual exploitation of minors Child abuse or neglect as defined in RCW First or second degree custodial interference Yes No Selling or distributing erotic material to a minor Malicious harassment Custodial assault First, second or third degree child molestation Child buying or selling First or second degree sexual misconduct with a minor First degree promoting prostitution First or second degree murder Patronizing a juvenile prostitute Child abandonment First, second or third degree assault of a child Felony indecent exposure Promoting pornography Violation of child abuse restraining order Prostitution Or any of these crimes as they may have been renamed If your answer was yes to any of the above, please describe and provide the date(s) of the conviction(s) and the sentence(s) imposed: Have you ever been convicted of any of the following crimes relating to financial exploitation of a person 60 years of age or older, who has a functional, mental or physical inability to care for himself or herself or who is a patient in a state hospital: Yes No First, second or third degree extortion First or second degree robbery First, second or third degree theft Yes No Forgery Or any of these crimes as they may have been renamed If your answer was yes to any of the above, please describe and provide the date(s) of the conviction(s) and the sentence(s) imposed:
5 1. Have you ever been found in any dependency action to have sexually assaulted or exploited any minor or to have physically abused any minor? Yes No 2. Have you ever been found by a court in a domestic relations proceeding to have sexually abused or exploited any minor or to have physically abused any minor? Yes No 3. Have you ever been found in any disciplinary board final decision to have sexually or physically abused or exploited any minor or developmentally disabled person? Yes No 4. Have you ever been found in any disciplinary board final decision to have abused or financially exploited any person 60 years of age or older who ha a functional, mental or physical inability to care for himself or herself or who is a patient in a state hospital? Yes No 5. Have you ever been found by a court in a protection proceeding under Chapter RCW to have abused or financially exploited a person 60 years of age or older who has a functional, mental or physical inability to care for himself or herself or who is a patient in a state hospital? Yes No If your answer was yes to any of questions 1 through 5 above, please describe and provide the date(s) of the finding(s) and the penalty(ies) imposed. Authorization To Conduct Criminal History Check And Certification Of Disclosures I understand that in connection with my application for employment, Metro Parks Tacoma will be obtaining conviction criminal history record information about me from the Washington State Patrol and/or other national background screening agency. I hereby authorize Metro Parks to obtain such information. I understand that if I am hired, my employment is conditioned upon Metro Parks Tacoma's receipt of a satisfactory criminal history report. Additionally, UNDER PENALTY OF PERJURY, I certify that the information I provided above is true, correct and complete. I understand that any misrepresentation or omission in the above disclosure statement will be grounds to reject my application for employment or to discharge me from employment. Signature: Name (print): Date: We may request your fingerprints or other information to obtain a national report of your record of criminal convictions for offenses against persons, civil adjudication of child abuse and disciplinary board final decisions. If you are hired before that report is available, YOUR EMPLOYMENT WILL BE CONDITIONED UPON THE RECEIPT OF A SATISFACTORY REPORT. You will be notified of an unsatisfactory response within ten days after we receive the report.
6 COACHES AGREEMENT As a Northwest Youth Sports Alliance (NYSA) coach and representative of Metro Parks Tacoma (MPT) and the Boys & Girls Clubs of South Puget Sound (BGCSPS), I understand and embrace the responsibility I have to provide a safe, educational, and positive environment for ALL players and parents involved in the youth sports program. By taking the responsibility of head or assistant coach for an NYSA team, I agree to the following: I will place the emotional and physical well-being of my players ahead of a personal desire to win. I will treat each player as an individual, remembering the large range of emotional and physical development for the same age group. I will do my best to provide a safe playing situation for my players I promise to review and practice the basic first aid principles needed to treat injuries of my players I will do my best to organize practices that are fun and challenging for all my players. I will lead by example in demonstrating fair play and sportsmanship to all my players. I will provide a sports environment for my team that is free of drugs, tobacco, and alcohol and I will refrain from their use at any NYSA sanctioned event. I have read and agree to abide by the Northwest Youth Sports Alliance Zero Tolerance policy. I will be responsible for informing my players and their parents of this policy. I am responsible for the actions of my players, parents, and fans during all NYSA events and understand that disciplinary action may be taken against me for their behavior. I have received the rules and regulations for the sport league for which I am coaching. I will abide by these rules and I will inform the players and parents on my team of these rules. If I feel a rule is unclear, I will ask an NYSA representative to clarify it for me. I will ensure that all my assistant coaches are informed of and will abide by all rules and standards set forth in this agreement. I understand that volunteer coaches are not permitted to transport or drive any players other than their own children to or from NYSA sponsored activities. Please check box below if you agree to: I will allow the NYSA to post my name, phone number and address on the NYSA home page so that my players can communicate more effectively with me. Coach s Name (please print) Team Name Coach s Signature Date
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