KidSafe, A Risk Management Program

Employment/Volunteer Application and Disclosure Statement
I understand that my employment/volunteer position with VYSA or any of its members is contingent upon my truthful completion and VYSA's or any of its members' review of this form. I authorize and understand that VYSA or any of its members may obtain a criminal history report, and that I may be requested to provide a set of fingerprints. I understand that I may be immediately discharged for any misrepresentation or material omission on this form. I understand that pending arrest or closed arrest is not an automatic bar to consideration of my application but it is the intent of VYSA or any of its members to deny a position to any person who has been convicted of sexual abuse, physical abuse or exploitation of any minor. I understand that VYSA or any of its members will take into account the nature of the of the offense, the date of the offense and the relationship between the offense and the position for which I am applying and any mitigating factors
Please sign and date

Signature:                                                           Date:                   .

Personal Information

Name Home Phone 
Address Work Phone 
   Date Birth 

Employer Name Address

   Drivers License #  
    Soc. Sec. #  
League/Club/Team Affiliation   Previous club if less than 3 years at present  
Position Applying For   Division  
       

   Please Circle "Yes" or "No" To The Following Questions

Have you ever been arrested for or convicted of sexual abuse, physical abuse or exploitation of any minor?      YES   NO
Are you now using illegal drugs?     YES   NO
Are you subject to any civil restraining order or any type of civil action relating to child or domestic abuse or violence?     YES   NO

If you answered yes to any of the above questions, please provide below detailed information as to the nature of the offense, the number of separate offenses in question, the date of the offenses, the relationship between the offense and the position for which you are applying and any mitigating factors that should be taken into account.
Mail with your child's registration form or to the following confidential P.O. Box:

Kidsafe Coordinator
Vienna Youth Soccer
P.O. Box 348
Vienna, VA 22183