Name _______________________ Date ________ Social Security # ______________ Address____________________ City _____________ State/Zip __________________ HomePhone____________________BusinessPhone____________________________ Occupation________________ Job Title _____________________________________ Employer__________________ Date of Birth _________email____________________ EmployerAddress________________________________________________________ Community Affiliations(Clubs,Service Organizations, etc.) _______________________ Previous Volunteer experience(including baseball/softball) Year: ________ __________ Year_______ ___________________________________________________________ Do you have children in the program? ___ Yes ___ No If yes, at what level?________ Special Certifications: i.e. CPR, Medical, etc. __________________________________ Do you have a valid driver’s license? ______ Yes ____ No License # _____________
Accidents or traffic violations? _________ Yes ______ No If yes, explain:__________ ______________________________________________________________________ Have you ever been convicted of any crime(s)? Include in your answer if you have been on probation under a deferred adjudication order ____ Yes ____ No If yes, describe each in full: _______________________________________________________________________________ Have you ever been refused participation in any other youth programs? ___ Yes ___No If yes, explain:___________________________________________________ In which of the following would you like to participate? (circle one or more.) League Official Coach Field Maintenance Umpire Scorekeeper Manager Concessions Stand Other Requested team: __________________________ League: (circle one) T-Ball 5-Pitch Minor Major Junior Senior Challenger Division: (circle one) American National Please list three references, at least one of which has knowledge of your participation as a volunteer in a youth program: Name Phone
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I give permission for the Little League organization to conduct a background check on me which may include a review of criminal and child abuse records maintained by government agencies. I specifically authorize any agency that receives this form to release the information to RCELL. I also understand that if any information provided herein turns out to be false, I will be subject to immediate suspension from any position I have been appointed within the League. I understand that if appointed, my position is conditional upon the league receiving no inappropriate information on my background. I hereby release and agree to hold harmless from liability the organization that my provide such information. I also understand that regardless of previous appointments I may not be appointed to a volunteer position. If appointed, I understand that, prior to the expiration of my term, I am subject to suspension by the President and removal by the Board of Directors.
Applicant (please print)_______________________________ Date _______________
Applicant Signature ________________________________________________ Note: The local Little League and Little League Baseball, Incorporated do not limit participation in its activities on the basis of disability, race, color, national origin, gender, sexual preference or religious preference.
Local League Use Only:
Background check complete by league officer ______________________
On ________________________________________________________
Systems used for background check (minimum of one must be checked):
Sex Offender Registry □ Criminal History Records □
Only attach to this application, copies of background check reports that reveal convictions of this applicant.