New Jersey Youth Soccer
Employment / Volunteer Disclosure Statement

To remain in compliance with the directive specified by New JerseyYouth Soccer, Old Bridge Soccer League, Inc. has adopted the Kid Safe Program. In doing so, ".... Any person, who at any time could be expected, in the performance of his/her duties, to be alone with any registered player for any length of time must have on file a completed Disclosure Statement".

This form MUST be returned to:
Old Bridge Soccer League, Inc.
PO Box 5277
Old Bridge, NJ 08857
Attn: NJYS/EVDS.

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NAME (First, Middle Initial, Last)                      SOCIAL SECURITY NUMBER

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ADDRESS (City, State, Zip Code)

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PHONE (Home, Business)                  DATE OF BIRTH

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COACHING LICENSE                  REFEREE GRADE       STATE

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DRIVER'S LICENSE NUMBER       STATE       EXPIRATION

1. Background in work with youth.	Position	Year(s)
2. Experience in soccer	Position	Year(s)
3. Experience in youth soccer	Position	Year(s)
4. Previous residence(s) (for last 5 years)	City	State
5. Have you ever been convicted of a crime or disorderly offense?		YES	NO
If yes, please explain: (use back of form if necessary)
6. Have you ever been convicted of a crime against a person		YES	NO
If yes, please explain: (use back of form if necessary)

I understand that:
	a. It is the intent of New Jersey Youth Soccer to deny certification to any person who has been convicted of a crime of violence or a crime against a person
	b. This disclosure statement must be updated at least every two-(2) years.

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Signature                  Printed Name                  Date