Little League Baseball And Softball Medical Release Page 2
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1
2Name
Date _ _ _ _ _ _ _ _ _
Address _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
City
State
Zip _ _ _ _ _ _
Home Phone
Business Phone
- - - - -
E-mail Address
(optional)
Date of Birth
- - - - - - - - - - - - - - - - - - -
Occupation
Social Security # _ _ _ _ _ _
Employer _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Address _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Special professional
skills, hobbies:. _ _ _ _ _ _ _ _ _ _ _ _ _
Community affiliations (Clubs, Service Organizations, etc.);
Previous volunteer experience (including basebalVsoftball and year):
Do you have children in the program?YesONo 0
If yes, at what level? _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Special Certification (i.e. CPR, Medical, etc.): _ _ _ _ _ _ _ _ _ _ _
Do you have a valid driver's license: Yes
D
No
0
Driver's License#:
State _ _ _ _ _ _
Have you ever been convicted of or plead guilty to any crime(s): Yes 0 No
0
If yes, describe each in full: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Have you ever been refused participation in any other youth programs? Yes 0 No
0
If yes, explain: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
In which of the following would you like to participate? (Check one or more.)
League Official 0
Coach 0
Umpire 0
Field Maintenance 0
Manager 0
Scorekeeper 0
Concession Stand 0
Other
D
Please list three references, at least one of which has knowledge of your
participation as a volunteer in a youth program:
Name
Phone
As a condition of volunteering, I give pennission for the Little League
organization to conduct a background check on me, which may include a review
of sex offender registries, child abuse and criminal history records. I understand
that, if appointed, my position is conditional upon the league receiving no
inappropriate information on my background. I hereby release and agree to
hold harmless from liability the local Uttle League, Little League Baseball,
Incorporated, the officers, employees and volunteers thereof, or any other person
or organization that may provide such information. I also understand that,
regardless of previous appointments, Little League is not obligated to appoint
me to a volunteer position. If appointed, 1 understand that, prior to the expiration
of my term, [ am subject to suspension by the President and removal by the
Board of Directors for violation of Little League policies or principles.
Applicant Signature
Date _ _ _ _
Applicant Narne(please print or type) _ _ _ _ _ _ _ _ _ _ _ _ _ _
NOTE: The local Little League and Litrle League Baseball. Incorporated will not discriminate
against any person on the basis of race. creed, color, naTional origin. marital status, gender, sexllal
orientation or disability.
Local League Use Only:
Background check complete by league officer _ _ _ _ _ _ _ _ _ _ _
System(s) used for background check (minimum of one must be checked):
Sex Offender Registry Cl Criminal History RecordsCl
Only aTtach 10 this appliea/ion (:opies ofbaekgrollnd check reports that reveal COTTilie/ions of
{his applicant.
01-073-05
rev.
2006
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