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DEPEW LACROSSE CLUB, INC. COACHING APPLICATION 2015 – 2016
Return this form to:
Depew Lacrosse Club, Inc.
11 Woodgate Dr.
Lancaster, NY 14086
Attn: Coaching Director
or emailed to:
Coaching Registration& Authorization: (ALL PARTS OF THIS FORM MUST BE FILLED IN AND SIGNED!)
(Please Print or Type)
Last Name: First Name: Initial: Date of Birth:
Street: City/State: Zip:
Home #Work # Cell #
Email Address:
Current Place of Employment:
Position:
Past coaching experience:(indicate what capacity, i.e. head coach, asst. coach, manager, and dates)
This application may be downloaded, filled in and sent electronically.
Have you ever been arrested? (Y/N)_____ If so, list date, place and reason: ______
Have you ever been charged with any crime other than a minor traffic violation? (Y/N)______
If so, list date, place and reason: ______
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Have you ever been convictedof any crime other than a minor traffic violation? (Y/N)______
If so, list date, place and reason: ______
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Have been adjudged liable for civil penalties or damages involving sexual or physical abuse of children? (Y/N)_____ Explain: ______
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Have you ever been subject to any court order involving any sexual or physical abuse of a minor, including but not limited to domestic order for protection? (Y/N) _____
Explain:______
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Have you ever been terminated, resigned, or asked to resign from a position, whether paid or unpaid, due to complaints of sexual or physical abuse of a minor? (Y/N) _____
Explain: ______
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Please add any other information you would like the Board Members to consider regarding your application.
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REFERENCES:
Please list three references who may be contacted to verify the content of your application.
Name: Phone: Relationship:
Name: Phone:Relationship:
Name: Phone:Relationship:
As a coach in any capacity with Depew Lacrosse Club I will familiarize myself with and attempt to at all times adhere to the US Lacrosse Code of Conduct as well as any additional requirements set by Depew Lacrosse.
As a Depew Lacrosse Club Coach, I will be responsible for conducting myself as a positive role model for those players on the team I am assigned to coach. As a role model and positive influence, I will accept responsibility for not only my behavior and conduct but also the conduct of my coaching colleagues, managers, players and parents.
I further understand that all Depew Lacrosse Club Coaches are appointed by the Depew Lacrosse Club Board Members and that any Coach Positions are at all times, “at will.” I further understand that this is a volunteer position and that I will not receive monetary compensation or any other remuneration or fringe benefit for serving in this position.
I also acknowledge that inappropriate behavior of the coach or members of his or her staff could result in disciplinary action by the Depew Lacrosse Club Board Members who have the authority to remove any coach or manger at any time if it is determine to be in the best interest of the Depew Lacrosse Club and its members.
I certify that all the information I have provided is true and accurate to the best of my knowledge. I also understand that providing false or inaccurate information in this application will disqualify me from further consideration as a coaching staff candidate or will result in my immediate dismissal if named to a coaching position.
I certify that if chosen, I will have to attend the American Red Cross First Aid/CPR/AED courseat my own cost to obtain the proper emergency certification if not done so already.
I assume all risks and hazards incidental to such participation, including transportation to and from such activities and do hereby waive, release, absolve, indemnify and agree to hold harmless the Depew Lacrosse Club, the organizers, supervisors, sponsors, participants, for any claim arising out of an accident or injury to myself, except to the extent and in the event covered by accident and/or liability insurance held by the Depew Lacrosse Club, Inc.
By my signature below, I authorize the Depew Lacrosse Club to investigate all information regarding my background in consideration of this application, I hereby waive, release and forever discharge the Depew Lacrosse Club, it officers, directors and members from any liability for damages that may result from compliance with this authorization.
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Applicant SignatureDate