Lower Dauphin Falcons Youth Football

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LDYFA Coaching Application

* Applicant Name:

* Address:

* Phone Number:

* Email Address:

* Date of Birth:

* Coaching Position Applying For:

* Coaching Background:

* Other Experience Working With Youth:

* Do you use illegal drugs?:

* Have you ever been convicted of a criminal offense? (If yes explain in section marked Other):

* Have you ever been charged with child abuse or neglect? (If yse explain in block marked Other):

* Has your driver's license ever been suspended or revoked? (If yes explain in the block marked Other):

* Other than the above, is there any fact or circumstance involving you or your background that would call into question you're being entrusted with the supervision, guidance, and care of youth? (If yes explain in black marked Other):

* Other::

* References, Please list three references who are familiar with you character as it relates to working with youth.:

The information that I have provided may be verfied, if necessary, by contacting persons of organizations named in the application, or by a local/national criminal background check. I hereby release and agree to hold harmless from liability any person or organization that provides information. I also agree to hold harmless the Lower Dauphin Youth Football Association Inc. (LDYFA), and volunteers there of. I understand that I may be held accountable and responsible for any equipment belonging to LDYFA that I may have been issued or have in my possession.

In signing this application, I affirm that the information I have given is true and correct.

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LDYFA Coaching Application