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                                           KidSafe Disclosure Statement

                        Please fill out the form below and press Submit.  Most fields are required
Age Group Designation:
First Name:
Middle Initial:
Last Name:
Street Address:
Social Security Number:
City:
State:
Zip:
Home Phone:
Work Phone:
Email:
Date of Birth:
    The Neshannock Area Soccer Club is a private entity. It is a policy of the Board of Directors that each and every person who coaches soccer in the association must be subjected to random background checks.  In the state of Pennsylvania, these are done through Social Security Numbers or fingerprints. We have chosen to use Social Security numbers as a means to randomly check backgrounds for felony convictions. This mechanism has proven to be valuable in eliminating persons with felony convictions involving violence against people, including children.  This information is kept very safe and secure in locked filing cabinets in locked offices.  On April 1, 2006 this paper will be shredded.  This information appears on no mailing or other list.   If you choose not to provide your social security number, we thank you for your service to soccer, but you will be denied the privilege to coach. If you cannot completely fill out this form, please inform your club, which will replace you with another coach.

Residence for past five years (indicate street address, city, state and zip. Separate residences with (";")

You may leave this field blank if your address for the past five years is the same as above:

Have you ever been convicted of a crime of violence: Yes No (If YES, please explain below).
Have you ever been convicted of a crime against a person: Yes No (If YES, please explain below).
I UNDERSTAND THAT:
  • It is the intent of NASC, the Neshannock Area Soccer Club to deny any person the opportunity to coach, or be in contact with youth soccer players who has been convicted of any violent crime.
  • In applying for NASC Youth Soccer Coach the information that I have furnished on this form is subject to verification, which may include a criminal history check.
  • I cannot coach in-house or receive a travel permit until this form is on file at the office.
  • This disclosure statement must be updated every two years; this statement is for March 31, 2004 to April 1, 2006.
   I hereby acknowledge that I have reviewed this document and caused it to be electronically executed with the intent to be bound by the terms contained  therein.
  I hereby acknowledge that I have review this document and made the choice of signing and mailing it to the attention of the Webmaster at NASC PO Box 5144 New Castle, PA 16105

Signature________________________________

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