City of Gastonia- Authorization for Background Check

In compliance with the City of Gastonia's policy covering background checks for volunteer services and individuals who will work with minors, the Gastonia Parks & Recreation Department requires the following information. By completing and signing this form you are authorizing the City of Gastonia to conduct the necessary background check.

First Name

Middle Name

Last Name

Phone Number

What sport are you coaching/officiating:

Basketball

Soccer

Volleyball

Softball

Baseball

Flag Football

Dodgeball

Kickball

What age group are you coaching/officiating?

List place(s) of residence for last ten years:

How many places have you lived in the past 10 years?

Please list the complete address (including city, state, and zip code).

How many years did you live at this residence? (Should be a complete 10 years)

Please list two (2) complete addresses (including city, state, and zip code). Next to each address, list how many years you stayed at this address (should add up to a complete ten years).

Please list three (3) complete addresses (including city, state, and zip code). Next to each address, list how many years you stayed at this address (should add up to a complete ten years).

Please list four (4) complete addresses (including city, state, and zip code). Next to each address, list how many years you stayed at this address (should add up to a complete ten years).

Please list five (5) complete addresses (including city, state, and zip code). Next to each address, list how many years you stayed at this address (should add up to a complete ten years).

Please list six (6) complete addresses (including city, state, and zip code). Next to each address, list how many years you stayed at this address (should add up to a complete ten years).

Please list seven (7) complete addresses (including city, state, and zip code). Next to each address, list how many years you stayed at this address (should add up to a complete ten years).

Please list eight (8) complete addresses (including city, state, and zip code). Next to each address, list how many years you stayed at this address (should add up to a complete ten years)..

Please list nine (9) complete addresses (including city, state, and zip code). Next to each address, list how many years you stayed at this address (should add up to a complete ten years).

Please list ten (10) complete addresses (including city, state, and zip code). Next to each address, list how many years you stayed at this address (should add up to a complete ten years).

Please list all (11+) complete addresses (including city, state, and zip code). Next to each address, list how many years you stayed at this address (should add up to a complete ten years).

Driver's License Number:

Driver's License State:

Birthday:

Gender:

Race:

Social Security Number:

Sign Here

First Name

Last Name

Choose how to sign

Draw Type

I agree to electronically sign and to create a legally binding contract between the other party and myself, or the entity I am authorized to represent.

Date Signed

Authorization for Minors

(Must be signed if applicant is under the age of 18)

If under the age of 18, the signer certifies that he/she is the custodial parent or guardian of the above applicant. By my signature, I give permission for the applicant to participate in this program and to have his/her background checked.

Parent or Guardian Signature

Date Signed

For Office Use Only:

Sport or Program/ Center: _________________________________

Program Supervisor: _____________________________________