2015 CYM Volunteer Form

 2015 CYM Volunteer Form
To be kept on file at your parish
As a part of the Safe Environment Program of the Archdiocese of Milwaukee, parishes are to require
volunteer applications from adults working with minors. In the event a parish does not have a standard
form in place, this form may be used. A form required by a parish should take precedence over this form.
Name:
Address:
City :
State:
Day Phone:
Zip :
Evening Phone:
Parish/Town:
E-mail:
Birthdate (required)
Emergency Contact:
Phone
Have you given permission for a Criminal Background Check in the past?
Yes
No
If yes, please indicate approximate date and name of parish/organization:
May we contact that parish/organization to verify the results of that check?
Have you completed the Safeguarding All of God’s Family Program: __ Yes __ No
If so, approximate date of completion, and parish at which you were a member:
___________________________________________________________________________
Coaching Experience
Have you coached CYM Sports before?
If yes, please list sports, dates, & parish(es):
Have you coached other youth sports before?
If yes, please list sports, dates, & parish(es):
Yes
No
Yes
No
Are you active in any other parish organizations? (please list)
Are you certified in First Aid?
Yes
No
CPR?
Yes
No
Have you ever been disciplined or removed by another parish program, or by any other
youth serving organization?
No
Yes, please explain:
2015 CYM Volunteer Form
References and Background Information
Based on our scriptural belief in the dignity of all persons, we commit to providing a safe environment for all people
using our premises and programs. This part of our enrollment form is to be completed by everyone who regularly
volunteers for any position involving care, supervision, or instruction of minors. It is a critical part of our church's
efforts to provide a safe and secure environment for children and young people in our care.
Personal References
These references will be checked randomly or as circumstances warrant. Please provide the name and phone of two
personal references:
Name:
Relationship:
Phone:
Name:
Relationship:
Phone:
Have you ever been convicted of, pled guilty or no contest to an offense (including felony, misdemeanor or municipal
ordinance) or are you now subject to a pending criminal charge? (Please check):
No
Yes, please explain:
(Note: Convictions are not an automatic bar to all participation as a volunteer. Each case is considered on its own merit.)
Please read and sign the following statement:
I certify the information provided by me above is true and complete to the best of my knowledge. I understand that
any false statements or omissions may lead to the termination of my duties, and I agree that the Archdiocese of
Milwaukee and its agents shall not be held liable in any respect if my volunteer assignment is terminated for any
reason.
I agree to abide by the parish and league rules, the Code of Conduct, and the directions of officials as a volunteer coach.
As one who works with youth on a regular basis in the CYM Sports program, the Archdiocese of Milwaukee and/or its
agents are authorized by me to verify the information stated above by means of criminal records checks. I agree to
follow established policies and I pledge to join with the church in its efforts to provide a safe and secure environment
for youth.
Signature:
Date: