Risk Management Application

The Kid Safe program instituted by the National Risk Management Committee mandates that volunteers be screened and a background check performed prior to being accepted as a volunteer and every 2 years thereafter as long as the volunteer is active in youth soccer.
Affiliation Information
WSYSA
District
Association
Club
Referee
If you are involved in multiple organizations, choose the one you are most active in.
If you cannot find an option that suites you, select WYS.
Primary Role:
If you hold multiple roles just choose the one you are most active in.
Title/Position:

Personal Information Do not fill in applications for someone other than youself without a signed consent form!
(Legal) First Name:
(Legal) Middle Name:
(Legal) Last Name:
Alias, Maiden Name, or Nick Name:
Date Of Birth:   (mm/dd/yyyy format)
Address:
City:
State:
Zip:
Home Phone:
Work Phone:
Cell Phone:
Email:
Gender:
Secondary dissemination of this criminal history record information response
RCW 10.97.050.


Risk Management Information
Have you ever been convicted of a crime of violence, crime against a person or a felony?

YesNo
If YES, please attach explanation:


Authorization for Background Check
I understand that:

  1. Washington Youth Soccer may deny a clearance to any person who has been convicted of a felony, crime of violence or a crime against a person.
  2. In applying to Washington Youth Soccer (WYS), the information I have furnished on this form is subject to verification, which will include a criminal history check.
  3. This is a reoccurring verification process and by submitting this application, that I (the applicant) authorize Washington Youth Soccer (WYS) to continue the verification process until I (the applicant) revoke this authorization in writing.
  4. By signing this application, that I (the applicant) assume the responsibility of notifying Washington Youth Soccer (WYS) of any changes to the information contained within this application.

By signing and submitting this application to Washington Youth Soccer (WYS), I authorize Washington Youth Soccer (WYS) to request a criminal history background check, as authorized by the Child/Adult Abuse Information Act. This request will permit Washington Youth Soccer (WYS), pursuant to RCW 43.43.838 to obtain a report of my criminal convictions; Disciplinary Board final decisions and subsequent criminal charges associated with the Disciplinary Board's final decision; and the record of Civic Adjudication pertaining to offenses against children.

By submitting this form I hereby release all persons, companies, corporations or individuals from all liabilities and responsibility that may result from providing Washington Youth Soccer (WYS) the information set out herein, including but limited to any claims whatsoever for defamation, fraud, misrepresentation, negligent or intentional infliction of emotional distress, discrimination violation of public policy, and any other potential claims, demands, liabilities and/or actions of any kind whatsoever, whether known or unknown to me in writing on the document entitled 'Employee/Volunteer Disclosure Statement.' Washington Youth Soccer (WYS) will use the report ONLY for the purpose of making its decision to permit me to act as a Washington Youth Soccer (WYS) Volunteer, and for no other purpose.
I declare under penalty of perjury under the laws of the State of Washington that the foregoing information is true and correct.
YesNo
 (please choose one, if you choose "No" then you cannot continue)
Please type your full legal name below.
Signed by::
If you are completing this application for another person, please note you must have this form signed by that individual and on file with WYS.