Kids Safe Form 

1. Please print this document.
2. Fill in your information.
3. Mail to address listed below.

________________________ ________________________ ________________________

First Name & Initial

Last Name

Social Security Number

________________________ ________________________ ________________________

Address

Town

State and Zip code

(      )_________________ (      )_________________ ________________________

Home Phone

Business Phone

Date of Birth

________________________ ________________________ ________________________

Coaching License

Referee Grade

State

________________________ ________________________ ________________________

Drivers License Number

State

Expiration

    1. Background in work with youth

 Position___________________________ Year(s)____________

    2. Experience in soccer

 Position___________________________ Year(s)____________

    3. Experience in youth soccer

 Position___________________________ Year(s)____________

    4. Previous residence(s) (for last 5 years)

 City______________________________ State______________

    5. Have you ever been convicted of a crime or disorderly person offense? If yes, please explain (Use back of form if necessary)

 ÿ Yes     ÿ No  

    6. Have you ever been convicted of a crime against a person? If yes please explain (Use back of form if necessary)

 ÿ Yes     ÿ No  

I understand that:
  1. It is the intent of New Jersey Youth Soccer to deny certification to any person who has been convicted of a crime of violence or a crime against a person.
  2. This disclosure statement must be updated at least every year.

________________________ ________________________ ________________________

Signature

Printed Name

Date

THIS FORM IS TO BE MAILED TO:
LVSA Kidsafe Coordinator
P.O. Box 230
Long Valley, NJ 07853