Windham Youth Cheerleading Background Check Verification Application
Name
*
First Name
Last Name
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Birth Date
*
-
Month
-
Day
Year
Date
Social Security Number (SSN)
*
Driver's License Number
*
Have you had any other names in the past (i.e. maiden names)? Please list them all. If not input N/A.
*
1. Have you ever been charged with, convicted of, plead no contest or guilty to any crime(s) involving or against a minor, or of a sexual nature?:
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Yes
No
If Yes to no. 1 above, describe each charge in full including date of court action and address of the court involved:
*
2. Have you ever been convicted of or plead no contest or guilty to any crime(s)? (You do not need to report traffic violations such as speeding tickets).
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Yes
No
If Yes to no. 2 above, describe each charge in full including date of court action and address of the court involved:
*
3. Do you have any criminal charges pending against you for any crime?
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Yes
No
If Yes to no. 3 above, describe each charge in full including date of court action and address of the court involved:
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4. Have you ever been refused participation in any other youth programs and/or listed on any youth organization ineligible list?
Yes
No
If Yes to no. 4 above, list all youth programs/organizations:
*
Note, the conviction of a crime must be discussed on a case-by-case basis by the Board of Directors.
Consent for Background Check (All applicants):
I understand that my relationship to Windham Youth Cheerleading as a volunteer is an “at will” relationship and that I or Windham Youth Cheerleading may terminate the relationship at any time without cause. My signature below constitutes authorization to check my employment history, including without limitation, my criminal arrest and conviction record, references and release of investigatory information possessed by any state, local, or federal agency. I further authorize those persons, agencies or entities to fully provide Windham Youth Cheerleading any information on the matter set forth above. I expressly waive in connection with any request for or provision of such information, any claims, including, without limitation, defamation, emotional distress, invasion of privacy, or interference with contractual relations that I otherwise might have against Windham Youth Cheerleading, it’s agents and officials, or against any provider of such information. The Windham Youth Cheerleading Board requires that everyone applying to volunteer with Windham Youth Cheerleading reads and signs this agreement. Coaches and volunteers need to be aware of the need for confidentiality regarding any child-related information. My signature below authorizes Windham Youth Cheerleading to conduct a criminal background check on me and to check my personal references. I give consent to this disclosure and agree to hold harmless from liability Windham Youth Cheerleading and any other persons or organizations providing such information. I understand that the information submitted in this application may be reviewed by an interview team to include WYC Board members. Sign Here:
*
Date Signed:
For minors Volunteers/Assistants it is required a parent/legal guardian signs below on behalf of applicant:
Date Signed:
Parent/Legal Guardian Full Name
First Name
Last Name
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