VOLUNTEER/COACH REGISTRATION FORM
Organization:
Division: _____________________________
Last Name:
First: Home Phone: ___Work:
Address:
____City: State: Zip:
Gender: M F
Social Security Number: Drivers License Number: ______
Date of birth: ____ -____-____ (Must be 18 yrs. old) Medical Insurance Carrier:
______________________________
Have you ever been suspended from another Organization? Yes No If so, Date suspended: _______________
Length of Suspension: _____________________ What Organization: ______________________________________
Volunteer Position:
Child’s Name if participating: _________________________________
Have you attended a coaches’ certification/training class? Yes No Year(s) attended:
______________________
I am interested in: Head Coach Asst. Coach Other: ________________________________________
Professional Reference (work, school, church etc.): Name:
Phone:
Personal Reference (non-relative): Name:
Phone:
WAIVER, CONSENT AND RELEASE OF LIABILITY:
I hereby consent to the investigation and verification of all information given in this application, including searches of law enforcement and
public records (including driving record and criminal background checks, and reference interviews). I hereby release and hold harmless Knox
County, its officers, employees and volunteers and any person or organizations that provides information for or to Knox County concerning
the use of or any attempt to verify the information provided in this application. I declare that all of the information given by me in this
application is true and complete to the best of may knowledge, and I understand that any misrepresentation or omission may be cause for
suspension or dismissal from my volunteer status with Knox County. If accepted as a volunteer, I hereby agree to abide by the Knox County
program Bylaws, policies, and decisions of Knox County.
DISCLAIMER, ASSUMPTION OF RISK AND WAIVER:
For myself and on behalf of my heirs, assigns and next of kin, I acknowledge that participation in this program may include travel,
participation on adverse field conditions, and risk of physical injury or death. For myself and on behalf of my heirs, assigns and next of kin, I
willingly and voluntarily accept and assume all such risks of participation. I hereby release, discharge and agree to hold harmless Knox
County, its employees, volunteers, officials, sponsors and other representatives from any and all claims, demands, costs, expenses and
compensation arising out of or in a any way related to any injury or other damage that may result to me while participating in this Knox
County sponsored activity. I acknowledge that Knox County does not provide medical insurance of any kind to participants.
DISCLOSURE STATEMENT:
I have read and understand that I may be disqualified and prohibited from serving as a volunteer of Knox County if among other things, I have:
1) Been convicted (includes crimes of record which have been expunged and pleas of “no contest”) of a crime of child abuse, sexual assault of
a minor, physical abuse, causing a child’s death, neglect of a child. Murder, manslaughter, felony assault or any assault against a minor,
kidnapping, arson, criminal sexual conduct, prostitution related crimes, controlled substance crimes, or any felony.
2) Been adjudged liable for civil penalties or damage involving sexual, physical, or verbal abuse of children.
3. Been subject to any court order involving any sexual, physical or verbal abuse of a minor, including, but not limited to a domestic or
protection order.
4) Had parental rights terminated.
5) A history with other organizations of complaints of sexual, physical or verbal abuse of minors.
6) Resigned, been terminated or been asked to resign from a position whether paid or unpaid, due to a complaint of sexual, physical or verbal
abuse of minors.
7) A history of behavior that indicates I may be a danger to children in the Knox County Program.
I HAVE READ THE WAIVER, CONSENT AND RELEASE OF LIABILITY, DISCLAIMER, ASSUMPTION OF RISK AND WAIVER. I HAVE READ
AND AGREE TO ABIDE BY THE KNOX COUNTY SPORTS CODE OF CONDUCT. I FULLY UNDERSTAND THE TERMS OF EACH AND AGREE
TO THESE TERMS FREELY AND VOLUNTARILY AND WITHOUT INDUCMENT OF ANY KIND.
Signature: Date:
League Commissioners Signature: Date:
Knox County Parks & Recreation \ 2447 Sutherland Avenue \ Knoxville, TN 37919
Questions? Call: 865. 215.6600
