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Hearts for Youth PO Box 414 ● Alexandria Bay, NY 13607 ● (315) 482-9971 x2130 ●

Coach/Chaperone Application Please print all information requested except signature:

Personal Information: Name: __________________________________________________________________ Last First middle initial maiden

Present Address:________________________________________________________ Lived at this address how long?____________________ If less than 3 years: Past Address: _____________________________________________________________ Social Security no._________________________________ Telephone: _______________________________

Age: ____________

Chaperone/Coach for: __________________________________________

Criminal Background: HAVE YOU EVER BEEN CONVICTED OF A CRIME? _______ Yes ______ No If yes, explain number of conviction(s), nature of offense(s) leading to conviction(s) , how recently such offense(s) was/were committed, sentence(s) imposed, and type(s) of rehabilitation.____________________________________________________________ ________________________________________________________________________ ________________________________________________________________________

Do you have a Drivers License? _________ Yes ___________ NO Drivers License Number__________________________ State it was issued:__________ I give Hearts For Youth permission to do a background check. I understand if something is found on my record I may not be able to coach or volunteer.

______________________________ Signature

______________________ Date

Coach/Chaperone Application