AIYSA Coaching Application & Background Check
			Youth Leadership Request
			Pursuant to KRS 17.160
		Organization:				Anderson Independent Youth Soccer Association (AIYSA)
			Address:			c/o 2314 Alton Station Road, Lawrenceburg, KY 40342
		Contact Person:				Julia Gustafson
		Phone Number:				(502) 839-81922
		Tax Exepmt Number:				D16175
Background Checks are performed by:					The Background Check Process
Administrative Office of the Courts					The records requested will be returned to the mailing address (AIYSA) on a
Pretrial Services					postage paid self-addressed return envelope to AIYSA.  A separate addressed
100 Millcreek Park					envelope on each person on which the Background Check has been requested
Frankfort, KY 40601					is required and is provided by AIYSA in order that individuals get to see the
(800) 928-6381					results of their Background Check.
					If you have any questions regarding the results of your Background Check,
					especially accuracy, please contact Pretrial Services @ (800) 928-6381.
Please Print or Type Information Clearly
Social Security Number:
Driver's License Number:
Date of Birth:
Full Name:
Maiden or Alias Name:
Street Address/ P.O. Box
City, State, Zip Code:
AIYSA Coaching Information:							Age Group:  ______________
Home e-mail:						Work e-mail:
Home phone:						Work phone:
What State did you live in for the last 6 months?
List in Chonological order with dates, other states that you have lived in over the last 20 years?
Have you ever been removed or restricted from youth coaching in any sport?								YES	NO	(Circle One)
Have you ever been convicted of a violent crime?								YES	NO	(Circle One)
Do you have any convictions involving drugs?								YES	NO	(Circle One)
Do you have any convictions that involve physical or sexual abuse?								YES	NO	(Circle One)
Do you have any convictions as a sex offender?								YES	NO	(Circle One)
I pledge that the information that I am providing is true & accurate, and if false, I understand that I may not
be able to serve as a coach.
Signed:							Date:
	(AIYSA reserves the right to determine the suitability of any individual for coaching)