P.B.A. 56                           P.B.A. 105

P.O. Box 5081        Phillipsburg NJ  08865

COACHES APPLICATION

DATE    NAME

ADDRESS

DO YOU HAVE CHILDREN PARTICIPATION IN ANY PAL PROGRAMS AT THIS TIME?  YES NO

IF YES,WHICH ACTIVITY

BIRTHDATE

PLACE OF BIRTH

ARE YOU CERTIFIED TO COACH DESIRED ACTIVITY AT THIS TIME?   YES NO

IF YES, GIVE CERTIFICATION CARD NUMBER AND THE AGENCY CERTIFIED WITH:

LEVEL OF CERTIFICATION

EMAIL PHONE

COACHING EXPERIENCE IN DESIRED ACTIVITY

OTHER ACTIVITIES YOU HAVE COACHED OR ARE CERTIFIED TO COACH

HAVE YOU EVER BEEN RELIEVED OF YOUR COACHING DUTIES ON A NON-VOLUNTARY BASIS?  YES NO

IF YES, WHEN AND WHERE:

PREVIOUS ORGANIZATION NAME AND ADDRESS

ON WHAT CONDITION DID YOU LEAVE PRIOR TEAM OR ORGANIZATION?

HAVE YOU EVER BEEN CONVICTED OF A CRIME?  YES NO

IF YES, WHEN AND WHERE:

HAVE YOU EVER BEEN INVESTIGATED FOR ANYTHING INVOLVING CHILDREN/JUVENILES?  YES NO

IF YES, WHEN AND WHERE:

WOULD YOU BE WILLING TO WAIVE YOUR RIGHTS TO PRIVACY AND SUBMIT YOURSELF TO A CRIMINAL HISTORY CHECK?  YES NO

WAIVER OF PRIVACY: I WAIVE MY RIGHTS TO PRIVACY AND ALLOW THOSE PERSONS RESPONSIBLE OF CHECKING MY CHARACTER AND CRIMINAL HISTORY ON MY, KNOWN AS NCIC/SCIC CCH, BUT NOT LIMITED TO PRIOR STATED CRIMINAL HISTORY CHECK.