Youth Sports Adult Participant Application

I wish to assist/participate in the below named organization. I understand any false information, omission of information, or misrepresentation of facts on this application is punishable by Section 837.06, F.S. as a misdemeanor of the second degree and will result in the denial of my privilege to participate in any youth sports organization in St. Johns County.

My league/organization is: Julington Creek Baseball
Position applying for is:
First Name: Last Name:
Alias(es):
Address: City: State: Zip:
Social Security Number: To be made available upon request if required for background check
Driver’s License Number: State
Date of Birth (YYYY-MM-DD): Place of Birth
Sex Male Female
Do you have child/children participating in the program? Yes No
If yes, give name of each child
How long have you been a Florida resident?
If less than five (5) years at present address, please provide prior address(es) for the last five (5) years:

Do you have any previous adult participant experience in your sports? Yes No.
If yes, please describe:

AUTHORIZATION FOR RELEASE OF INFORMATION

I, the undersigned, authorize the release to St. Johns County Recreation and Parks Department/ CAA Soccer any record or information concerning my (Name of St. Johns County youth organization) driving record and any crime committed or alleged to have been committed by me. This includes, but is not limited to, arrest records and conviction data. I hereby release any governmental, police, or other agency as custodian of such records, including all officers, employees, or related personnel, both individually and collectively, from any and all liability for damages of any type which may at any time result to me, my heirs, family, or associates, because of compliance with this authorization. I also understand that all information about myself pertaining to this application may be considered public record. If a record of criminal convictions or other disqualifying information is found, the adult participant will be given a copy of the criminal history report and asked if it is accurate prior to any final decision. If the adult participant disagrees with the accuracy of the report, it will be up to him/her to provide any or all documentation to support his/her claim. Child safety being paramount, any uncertainty will be handled in favor of promoting child safety. I hereby waive any right to assert that such investigation or request constitutes an invasion of my privacy. I recognize that such inquiries are in the interests of all persons involved in youth sports activities, and I fully consent to such investigations. I, the undersigned, for myself, my heirs, executors, administrators, and representatives, do hereby remise, release and forever discharge and agree to indemnify and hold harmless any involved background check vendor and/or licensed private investigator, St. Johns County, its directors, officers, employees, volunteers, agents and representatives, its affiliates and sponsors, and their directors, officers, employees, volunteers, agents and representatives, as well as third parties, if any, that St. Johns County or its affiliates contact, directly or indirectly, regarding my application to, or future services with, St. Johns County, from and against any and all causes of actions, suits, liabilities, costs, debts, and sums of money, claims and demands whatsoever, and any and all related attorneys’ fees, court costs, and other expenses resulting from the investigation of my background in connection with my application to become an adult participant. I understand and agree that St. Johns County/Youth Sports Association may, at each their sole discretion, decline to accept my application for, or participation in, volunteer/staff services with or without cause. I ACKNOWLEDGE THAT I HAVE READ AND FULLY UNDERSTAND THE ABOVE CERTIFICATION / CONSENT FOR CRIMINAL BACKGROUND CHECK / AUTHORIZATION / WAIVER / RELEASE / INDEMNITY, AND THAT I ACCEPT AND SIGN THIS FORM VOLUNTARILY.

If necessary, would you agree to be fingerprinted? Yes No