VOLUNTEER APPLICATION
To be a Volunteer for the Selma Parks and Recreation Department, you
must complete this application. Please PRINT legibly using either blue or
black ink.
PERSONAL INFORMATION:
FULL LEGAL NAME:
LAST
FIRST
STREET
CITY
CELL
HOME
MIDDLE
ADDRESS:
STATE
ZIP
PHONE:
BUSINESS
EMAIL ADDRESS:
IN CASE OF AN EMERGENCY CONTACT:
NAME
RELATIONSHIP
PHONE:
CELL
HOME
BUSINESS
COACHING INFORMATION:
COACHING DESIRED (CIRCLE ONE):
HEAD COACH
SPORT:
ASSISTANT HEAD COACH
SEASON:
AGE GROUP (CHECK ALL THAT APPLY):
 6U
 8U
 10 U
 12 U
HAVE YOU COACHED PREVIOUSLY?
 15 U
 YES
 18 U
 NO
IF SO, WHEN?
WHERE?
WHAT LEVEL?
HAVE YOU PLAYED THE SPORT YOU ARE REQUESTING TO COACH?
Page 1 of 4
 YES
 NO
Revised: 11/26/2013
THREE PERSONAL REFERENCES (NOT RELATED TO YOU):
NAME
PHONE NUMBER
APPLICANT’S CERTIFICATION, AGREEMENT, WAIVER OF LIABILITY AND RELEASE:
(Please read the following information carefully before signing.)
I hereby certify that all statements on this application are made truthfully and without expansion, and I
further understand and agree that such statements may be investigated and if found to be false will be
sufficient reason for not being accepted as a Volunteer, or if accepted may result in my dismissal.
I agree to abide by all program rules and regulations set forth by the Selma Parks and Recreation
Department. I understand that there are certain inherent risks involved in any activity. I do hereby waive,
relinquish, release, discharge and hold harmless the Town of Selma and its employees, volunteers,
contributing sponsors and affiliate organizations from any and all liability for any physical or mental injury
or aggravation of any pre-existing condition, illness or disability, death, loss of enjoyment or any other
harm or loss of any nature which may be sustained by me while serving as a Volunteer for the Selma Parks
and Recreation Department.
APPLICANT’S AUTHORIZATION AND CONSENT FOR RELEASE OF INFORMATION:
This release and authorization acknowledges that the Town of Selma may now, or at any time while I am
employed, contact personal references, obtain social security verification, search the sexual offender
registry and receive any criminal history record information pertaining to me which may be in the files of
any Federal, State or Local criminal justice agency, and to verify any other information deemed necessary
to fulfill the job requirements. The results of this verification process will be used to make employment
decisions pursuant to the Town of Selma’s employment policies.
I hereby authorize the Town of Selma’s designated representative and the Town’s current
employment verification vendor and any of its associates, to disclose orally and in writing the
results of this verification process to the authorized representative of the Town of Selma. The
Town of Selma, may at its discretion, change its representative or vendor and this release will
remain in effect.
I have read and understand this release and consent, and I hereby authorize the background verification.
I authorize all persons, organizations and agencies to provide the Town’s designated representative or the
Town’s employment verification vendor, or its associates with all information that may be requested. I
hereby release all of the persons and agencies providing such information from any and all claims and
damages connected with their release of any requested information. I agree that any copy of this
document is as valid as the original.
Page 2 of 4
Revised: 11/26/2013
I do hereby agree to release and discharge the Town of Selma, the employment verification vendor and
their associates to the full extent permitted by the law from any claims, damages, losses, liabilities, costs
and expenses or any other charge or complaint filed with any agency arising from the retrieving and
reporting of information.
Please list any addresses you have had outside of North Carolina in last ten (10) years:
(PLEASE WRITE LEGIBLY.)
Printed Name, Last, First,
MI
Race
Sex
Social Security Number
Volunteer’s Signature
Date
Witness
Date
Date of Birth
THANK YOU SO MUCH FOR YOUR INTEREST IN BEING A VOLUNTEER!
Please return this completed and signed form to the Selma Parks and Recreation Department via email to
[email protected]. You may also mail it to or drop it off at the Selma Parks and Recreation
Department office located at:
305 N. Pollock Street
Selma, NC 27576
Page 3 of 4
Revised: 11/26/2013
Selma Parks and Recreation Department
COACHES CODE OF ETHICS PLEGE
I hereby pledge to live up to my moral obligations as a Selma Parks and Recreation Department
(SPRD) Youth Coach by following the below mentioned Code of Ethics:
I will place the emotional and physical well-being of my players ahead of my personal desire to win.
I will remember to treat each player as an individual, remembering that there is a large spread of
emotional and physical development in the same age group.
I will do my best to provide a safe playing situation for all my players.
I promise to review and practice the necessary first aid principles needed to treat the injuries of my
players.
I will do my best to organize practices that are fun and challenging for all my players.
I will lead by example as I demonstrate fair play and sportsmanship to all my players.
I will make sure that I am knowledgeable in the rules of each sport that I coach, and that I will teach
those rules to my players.
I will use coaching techniques that are appropriate for each of the skills that I teach.
I will refrain from the use of alcohol, tobacco and drugs at all games, practices and youth sporting
events.
I will conduct myself in an appropriate manner at all times for a youth recreational event by
refraining from the use of profanity, unsportsmanlike conduct or other objectionable behavior.
I will treat all players, coaches, parents, and officials with respect regardless of race, sex, creed or
ability.
I will remember that I am a youth coach, and that the games are designed for the children and youth
participants, not adults.
I will only allow players on my official team roster to participate during practice or games, unless
SPRD staff have approved any player changes.
I will never allow a child over the age division to farm down to play on my team roster. Only if
necessary with SPRD approval, will I farm up a registered player from the age division below.
I have read and understand the Selma Parks & Recreation Department’s youth athletic philosophy.
_____________________
Print Name
Page 4 of 4
________________________
Youth Coach Signature
_________
Date
Revised: 11/26/2013