South Dakota State Soccer Association
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 South Dakota State Soccer.

*Please note First Name as it appears on birth certificate.

Please fill out the form below and press Submit.
 
 
 
 
 
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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):
Answering "Yes" to any of the following inquiries may require SDSSA to make further inquiries before I will be permitted to begin my activities on SDSSA's behalf. It is the intent of US Youth Soccer and SDSSA to deny certification to any person who has been documented history of behavior deemed to be detrimental to the health, welfare, and safety of its members.

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I hereby grant to South Dakota State Soccer and its member organizations, the authority to obtain my criminal and driving record, if any. I understand that I agree to inform the above, if any any of this information changes. I also agree to be fingerprinted and photographed if necessary to confirm my identity and criminal history. I affirm under the penalties for perjury that the forgoing is true and accurate.

This disclosure statement must be updated a minimum of every (1) year, understanding that my signature below authorizes SDSSA to obtain periodic and criminal history checks during the year period. Further, I agree to indemnify and hold harmless the persons(s) to whom this request is presented and South Dakota Soccer Association from and against all claims, damages, losses and expenses, including reasonable attorney’s fees, arising out of or by reason of complying with this request.

Affiliation is contingent upon SDSSA'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.

By completing and submitting this disclosure statement electronically via the Internet, I agree to its terms and conditions stated above and my signature thereto may be implied. I acknowledge to follow all local association and SDSSA rules, policies, and procedures relating to South Dakota State Soccer. I further acknowledge to have and maintain at least the minimum amount of liability insurance as required by the State of South Dakota if at any time I am asked to use my personal or non-owned vehicle for youth affiliated youth soccer activity.

Signature


 
 

Questions?