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

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

HFY@alexandriacentral.org ● www.heartsforyouth.org

Coach/Chaperone Application