New Mexico Youth Soccer
Disclosure Statement For Certification


The information that you provide on this disclosure is stored on a secure server and will only be visible to the Risk Management staff at New Mexico Youth Soccer.

Please fill out the form below and press Submit.
 
 
 
 
 
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 Male    
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(Check "Do not have Drivers License" checkbox if you do not have one)

 
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Please Answer Yes or No to the following question(s):

  Yes     No 
  Yes     No 
  Yes     No 

I understand that:

  • Answering "Yes" to any of the above inquiries will require NMYSA to make further inquiries before I will be permitted to begin my activities on NMYSA's behalf. It is the intent of US Youth Soccer and NMYSA to deny certification to any person who has been convicted of a crime of violence or of a crime against a person or for any additional documented history of behavior deemed to be detrimental to the health, welfare, and safety of its members. The referenced documents and policies pertaining to denial, suspension, and revocation of coaching and/or administrator privileges are contained in the NMYSA Risk Management Program, which can be found on the Risk Management page of the NMYSA web site (http://www.nmysa.net/n-risk.html).
  • In applying for a US Youth Soccer / NMYSA position, the information which I have furnished on this form is subject to verification, which may include a criminal history check as well as fingerprinting.
  • This disclosure statement must be updated a minimum of every two (2) years, understanding that my signature below authorizes NMYSA to obtain periodic and possible re-occurring criminal history checks during the two year period. I understand that some level of certifications require that this disclosure statement must be updated more frequently than the two year period.
  • AFFILIATION IS CONTINGENT UPON NMYSA'S REVIEW AND APPROVAL OF THIS DISCLOSURE STATEMENT, TRUTHFULLY COMPLETED BY ME AND SIGNED. I FURTHER UNDERSTAND THAT IF I AM HIRED OR PERMITTED TO VOLUNTEER, I MAY BE DISCHARGED FOR ANY MISREPRESENTATION OR OMISSION ON THIS DISCLOSURE STATEMENT OR DISCOVERY OF A CRIMINAL HISTORY. I DECLARE UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.

By completing and submitting this disclosure statement electronically via the Internet, I agree to its terms and conditions and my signature thereto may be implied. This Electronic Signature qualifies under New Mexico Statutes—the Electronic Authentication of Documents Act and the Uniform Electronic Transactions Act.

Signature


 
 

Questions?