Brantley County Recreation Department Coaching Application

Name *

Address *

Phone Cell *

Email *

What sport do you wish to coach? Please check sport and division. *

Blast Ball

Tee-Ball

Football

Softball

Basketball

Soccer

Cheerleading

Age Division

6U

8U Girls

8U Boys

10U Girls

10U Boys

12U Girls

12U Boys

14U Girls

14U Boys

Do you wish to be a head coach or assistant?

Head Coach

Assistant

If choosen to a coach team, do you agree to abide by the rules set by Brantly County Recreation Department?

Yes

No

Signature *

Clear

Date *

Name-Based Criminal History Record Information (CHRI) Consent/Inquiry Form

I hereby authorize _ Brantley County Board of Commissioners/ L Daniels to conduct an inquiry for Agency/Company the purpose below and receive any Georgia and/or national CHRI as authorized by state and federal law.

Full Name *

Address - If different from above*

Sex *

Race *

Date of birth *

Social Security Number *

This authorization is valid for 180 days from date of signature.

*

,give consent to the above named entity to perform periodic criminal history background checks for the duration of my employment.

Signature *

Clear

Date *