Date of Birth
SCHOOL INFORMATION (If applicable)
Name of School
This is someone who is not a family member and over the age of 18
Reference #1 Phone
Reference #1 Cell
Reference #2 Phone
Reference #2 Cell
Reference #3 Phone
Reference #3 Cell
Permission for Doctors/Hospital
Any Medical problems and/or allergies
Please Indicate any medications presently taking
Are you a US Citizen to a legal resident of the US?
Do you have a valid driver license?
If, yes please indicate license number
Have you ever been convicted of any motor vehicle violations in the past 5 years? *
(Other than minor traffic violations)
Have you been convicted of, pled guilty to, and/or pled nolo contendre to a crime? *
(felony or misdemeanor, including but not limited to sexual offender crimes, theft, banking fraud, drug and/or alcohol-related offenses, assault, etc.)
If yes, how many hours and when must you completed by:
PREVIOUS COACHING / VOLUNTEER EXPERIENCE/ WORK EXPERIENCE
List three coaching or volunteering experiences you have had with children under the age of 18
Program Interest or Sport you wish to coach:
When would you be available to volunteer?
Physical or mental limitations:
Volunteering in the State of Maine is considered an at-will opportunity. By signing this application I attest to the fact that the information provided is true, correct and complete. Any misstatement, omission of fact or misrepresentation on this application may result in dismissal. I authorize the Boys & Girls Clubs of Kennebec Valley to conduct a background check on me through the State Police, National Agency Check, Department of Human Services and the Department of Motor Vehicles to verify the information provided if over the age of 18.