APPLICATION & DISCLOSURE STATEMENT

The Southern Amateur Hockey Association (SAHA) of USA Hockey will not authorize or sanction participation of any volunteer or employee in any programs that it directly controls if such person has routine access to children (anyone under the age of majority,) and refuses to consent to a criminal background check by SAHA or a designated third party representative. PLEASE NOTE: All information will be maintained by SAHA, in strict confidentiality. If there are questions please contact Background check form, print this page, complete fully, and mail to, Columbus Hockey Association, Inc.  308 Deer Run Drive, Ellerslie GA 31807.  706-566-7705

 

SAHA Volunteer

Application and Disclosure Agreement

(Please Print Legibly)

  1. Name:_____________________________________________________________________________                                              Last First Middle Other Names Used

  2. Club Association/POC /or USA Hockey CEP Number_________________________________________

  3. Position: Coach Assistant Coach Team Manager Board Member Other ____________

  4. Age bracket: Mite Squirt Peewee Bantam Midget

  5. Date of Birth____/______/______ Current Age _____________

  6. Race: _____American Indian/Alaskan Native _____Asian/Pacific Islander _____Black_____White_____Hispanic

  7. Social Security Number__________-___________-_____________

  8. Email Address: ____________________@_____________________

  9. Home Phone (_______)_______-________

  10. Business Phone (_______)___________-____________

  11. Other Phone (_____)__________-__________

  12. Driver's License Number_____________________________________State__________________                                                           

  13. Current Address__________________________________________________________________

    City:________________________________ State _____________________________ Zip Code _____________________

  14. List other states/countries you have lived in during the past 10 years (i.e. 1994-1996 Chicago, IL) ___________________________________________________________________________

    ___________________________________________________________________________

    ___________________________________________________________________________

  15. Have you ever been convicted (including crimes the record of which has been expunged and pleas of "no contest") of a crime of child abuse, sexual abuse of a minor, physical abuse, causing a child's death, neglect of a child, murder, manslaughter, felony assault, any assault against a minor, kidnapping, arson, criminal sexual conduct, prostitution related crimes or controlled substance crimes, __________Yes __________No

    If yes, please explain_________________________________________________________________

    __________________________________________________________________________________

    __________________________________________________________________________________

  16. Have you ever been subject to any court order involving any sexual abuse or physical abuse of a minor, including but not limited to a domestic order for protection? ____Yes ______No

    If yes, please explain_________________________________________________________________

    __________________________________________________________________________________

    __________________________________________________________________________________

  17. Have your parental rights ever been terminated? _______Yes ________ No

    If yes, please explain_______________________________________________________________

    ________________________________________________________________________________

    ________________________________________________________________________________

  18. Have any complaints ever been made against you either at work or in your capacity as a volunteer that you sexually or physically abused a minor? ________Yes _______No

    If yes, please explain_______________________________________________________________

    ________________________________________________________________________________

    ________________________________________________________________________________

  19. Do you have a history of any behavior that might make you a danger to any children/youth/adolescents in this hockey program? _________Yes ________No

If yes, please explain_______________________________________________________________

 

Applicant's Statement, Authorization and Release of Liability

I certify that all information given by me in this application is true and correct to the best of my knowledge. I understand that false or misleading statements made by me or consequential omissions of any kind in the application process are sufficient cause for my not being accepted as a volunteer/employee or for my dismissal no matter when discovered.

I authorize Southern Amateur Hockey Association (SAHA) to investigate all information contained in this application. The employers, organizations and individuals named are authorized to give you any and all information regarding my employment, volunteering, character, fitness and qualifications (including opinions) that they may have about me.

In consideration of the evaluation of this application by Southern Amateur Hockey Association, I HEREBY WAIVE, RELEASE AND DISCHARGE USA Hockey, Southern Amateur Hockey Association (SAHA), all employers, organizations, and individuals, and any other persons or entities from liability for all damages and losses of whatever kind or nature, except liability for willful or intentional acts or punitive damages, that may result from compliance or attempts to comply with this authorization.

__________________________________

Signature

__________________________________

Date

INSTRUCTIONS FOR COMPLETING THE

APPLICATION & DISCLOSURE STATEMENT
  1. Name – Complete birth name
  2. Club Association/POC: Indicate your affiliation (i.e., Arkansas Hockey Association, IceForum Kennesaw, Memphis Amateur Hockey League) and your affiliations registrar.
  3. Position: Circle your primary position with your affiliation.
  4. Age Bracket: If coaching, circle appropriate age bracket
  5. Date of Birth/Current Age: Enter Date of Birth as follows: mo/day/year and current age at time of Application.
  6. Race: Please indicate by checking your appropriate race
  7. Social Security Number: Please provide nine-digit social security number. If social number was not issued in the United States please provide country of origin.
  8. Email Address: Please provide either a personal or work email address.
  9. Home Phone: Please provide home telephone number including area code.
  10. Business Phone: Please provide work telephone number including area code.
  11. Other Phone: Please provide cellular telephone number or other number if available.
  12. Driver License Number: Please list driver’s license number and issuing state. If license was not issued in the United States, please list issuing country.
  13. Current Address: Include address, city, state and zip code. Please no abbreviations.
  14. Other Addresses: Please indicate other states/countries you have lived in during the past ten years. (i.e., 1993-1996 Chicago, IL; 1996-1998 Philadelphia, PA; 1998-2000 Atlanta, GA)
  15. Question 15-19: Please read each question completely and carefully. After reading each question check either the yes or no line. All questions that are answered with a yes answer will require you to explain further.

After reading the Applicant’s Statement, Authorization and Release of Liability sign and date and mail to address indicated.

INCOMPLETE AND ILLEGIBLE APPLICATIONS WILL NOT BE PROCESSED.