California Youth Soccer Association, Inc.
Team Official Registration And
Risk Management Disclosure Form


PROVIDING FALSE INFORMATION OR OMITTING INFORMATION WILL RESULT IN IMMEDIATE SUSPENSION FROM ALL CYSA ACTIVITIES

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 California Youth Soccer Association - North.

Please use Legal First Name and Legal Last name in the fields below.
Please fill out the form below and press Submit.
 
 
 
 
 
 )      
 )  Ext     
 )  
 
 /  /    
 Male    
You must complete one of the three ID's (SSN, Drivers License, Other ID).
 -  -  

(Check "Do not have Drivers License" checkbox if you do not have one)

 
 /  / 
  
 

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

  Yes     No 
1. I request to be fingerprinted so I may qualify to volunteer for or be employed by California Youth Soccer Association (Cal North) or operate under contract with one of our affiliate organizations. I also certify that I have no physical illness or impairment, which will make participation in soccer related activities dangerous to me. I understand that in requesting and being fingerprinted I may be disqualified or terminated ("Fail") for volunteering if, according to the guidelines approved by the Board of Directors, the results of the background check and review process shows evidence of moral turpitude, dishonesty, or fraud to such a degree as to cause the Board to be concerned for the wellbeing of those who would be associated with me as a volunteer.   I agree
2. I also understand that if I am arrested while I am registered as a volunteer with Cal North, a Subsequent Arrest Report (SAR) will be generated and forwarded to the Organization's Custodian of Records. Receipt of an SAR may result in suspension of my ability to volunteer and this possible suspension is at the sole discretion of the Custodian of Records.   I agree
3. I understand that the Chairman or designee will inform me if I “Fail” or am suspended and am not permitted to volunteer. I further understand that a copy of my report obtained from the Department of Justice which did not meet the volunteering criteria will be mailed to my address of record. I further understand that no specific information from an SAR or from the results of the background check will be disseminated to anyone not authorized by law.   I agree
4. If a suspension of volunteering is due to an SAR report, I understand that I may again be eligible to volunteer if the outcome of the SAR has a result which falls within the Board's volunteering guidelines. It shall be my responsibility to inform the Custodian of Records of the final outcome of the arrest with the appropriate legal documents. The Custodian of Records will then recommend to the President either a "Pass" or "Fail" with respect to my ability to volunteer.   I agree
5. I understand my only recourse to dispute a suspension or "Fail" is to file a written appeal through the Chairman or designee. The Chairman/designee will review all evidence submitted and issue a final adjudication which is not subject to further review.   I agree
6. I will abide by the rules and regulations set forth by the California Youth Soccer Assn, Inc., United States Youth Soccer, United States Soccer Federation and its affiliated Leagues and Clubs, including the acknowledgment of having and maintaining at least the minimum amount of insurance as required by the State of California per the State Vehicle Code. I agree to notify California Youth Soccer Association representatives that I do not have such coverage if at any time I am asked to use my personal or non-owned vehicle for affiliated youth soccer activities. Furthermore, I agree to not allow any person who does not have authorization and/or insurance to drive my vehicle for affiliated youth soccer activities.   I agree
7. I further understand that not every crime nor circumstance may be covered in the “Pass” or “Fail” guidelines put forth by the Board. For any area not specified by the Board as either “Pass” or “Fail”, I will abide by the decision of the designated Custodian of Records, understanding that he/she is making a decision which, in his/her opinion, will be in the best interests of the group, these actions subject to Chairman’s review. As such, I hold the League, the Board, and the Organization's Custodian of Records completely harmless for any decisions made which may adversely affect my ability to volunteer.   I agree
I declare under Penalty of Perjury under the laws of the State of California that the information that I have furnished on this form is true and correct to the best of my knowledge. By completing and submitting this disclosure statement electronically, I agree to its terms and conditions and my signature thereto may be implied. If I am submitting this form on behalf of another individual, I am attesting that I have the completed and signed California Youth Soccer Association’s Adult Registration and Team Management Disclosure Form (#1650) in my possession and will submit it to California Youth Soccer Association via the District Registrar.

Your Privacy Rights

Signature


 
 

Questions?