Volunteer Coach__________ - Guilford County Schools



Sport______________

Did this person coach last year yes ___ no ____

REQUEST TO CHECK CRIMINAL BACKGROUND ON VOLUNTEER COACH

(Please print)

Requesting School: _______________________________________________________ Date: ____________________

Volunteer Name: ____________________________________________________________________________________

last first middle maiden

List any other names used in the past: ______________________________ Social Security #: _________________________

Birth Date: ______________________________ Gender: ______________ Race: ____________

Present Address: ______________________________________________________________________________________

Years at this address:________________ Telephone number: ( )_____________________

Record of past address for last 10 years (use back of page if necessary)

from _______ to _______ _______________________________________________________________________________

year year street address city state zip

from _______ to _______ _______________________________________________________________________________

year year street address city state zip

from _______ to _______ _______________________________________________________________________________

year year street address city state zip

from _______ to _______ _______________________________________________________________________________

year year street address city state zip

Please list all felony or misdemeanor criminal convictions, guilty pleas, deferred prosecutions, prayer for judgments and pending charges. (Excluding minor traffic violations)

I certify that all the foregoing is complete, accurate and true and agree to notify the district of any change in the foregoing information. Further, I certify that I have never been convicted of criminal behavior which includes either an act of violence or of a sexual nature. I hereby authorize the Guilford County Board of Education, its designated employees or agents to secure any and all information on my background and direct the holders of any and all such information about me to release it to the Guilford County Board of Education, its designees and agents. I hereby expressly waive any claims against the holders of any such information for their compliance with this directive.

This release is only for approval as a volunteer coach. If the school administration determines it is necessary to change my status to a paid non-faculty coach, I understand that I must immediately complete the required paperwork to be approved as a paid non-faculty coach. Failure to do this in a timely manner will result in delayed payment or possible non-payment.

____________________________ ______ Please see reverse side for

Signature of prospective volunteer date Compliance Statement to sign.

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For office use only:

Date of in-state check:________________

Recommendation:

______ Encourage to volunteer with no conditions

______ OK to volunteer with following conditions: _____________________________________________________________________

_____ Deny as volunteer By: ____________________ Human Resources Designee Date: ___________

Revised 3/3/2011

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Compliance Statement

(Administrative Procedure KF-P)

I understand that as a volunteer coach I must abide by any

applicable rules and regulations of the North Carolina High

School Athletic Association, State Department of Public

Instruction, Guilford County Schools and the specific school(s)

at which I volunteer.

I also understand my participation as a volunteer coach may be

terminated at any time, without cause, and that I may withdraw

from volunteering at any time and for any reason.

____________________________________________________

Signature of prospective volunteer date

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