VOLUNTEER YOUTH
SPORTS COACH
Application Packet
DEPARTMENT OF THE ARMY
US ARMY INSTALLATION MANAGEMENT COMMAND
HEADQUARTERS, UNITED STATES ARMY GARRIZON, FORT SILL
Child, Youth and School Services
4700 Mow-Way Road, Suite 200
Fort Sill, Oklahoma 73503
I __________________________ give permission to the Fort Sill Child, Youth & School Services Program to run an
installation Records Check (background check) on myself in order to volunteer with the Child, Youth & School
Services or any other installation programs.
__________________________
__________________________
Signature
Date
1
DEPARTMENT OF THE ARMY
US ARMY INSTALLATION MANAGEMENT COMMAND
HEADQUARTERS, UNITED STATES ARMY GARRIZON, FORT SILL
Child, Youth and School Services
4700 Mow-Way Road, Suite 200
Fort Sill, Oklahoma 73503
IMSI-MWC
REPLY TO ATTENTION OF
CYS Services
Parent Central Services Office
LAWTON POLICE DEPARTMENT
ATTN: RECORDS SECTION
LAWTON, OK 73501
In order to assist this office in the evaluation of candidates being considered for civilian employment at Fort Sill,
certain information from your files would be of assistance. It would, therefore, be appreciated if your office would
complete the information indicated in the statement below and return this form to our office at your earliest
convenience.
Sincerely,
Ivory Marshall
PARENT CENTRAL SERVICES DIRECTOR (NAF)
I am an applicant or new hire for Nonappropriated Fund employment with the Department of the Army, Fort Sill,
Oklahoma. For determination of my potential and security clearance, I hereby authorize release of police record
information, if any, to the Department of the Army, Fort Sill, Oklahoma, officials.
__________________________
Signature of Applicant
POLICE RECORDS CHECK
Name:
Present Address:
-address-city, state, zip-
Date of Birth:
SSN:
Place of Birth:
-city, stateSex:
DO YOUR FILES REFLECT A POLICE RECORDS FOR THE ABOVE PERSON
YES [ ]
NO [ ]
(If yes, please list details on a separate sheet and attach)
_________________________________
Signature
Date
FS FL 22
(CPAC/NAF) Rev 17 Sep 03
2
REQUEST FOR BACKGROUND NAME CHECK
Directorate of Emergency Services
CRIMINAL RECORDS
INFORMATION REQUEST
(check one)
Arms Room [ ] Mail Room [ ] Security Clearance [ ] Drug & Alcohol [ ] Child Care Provider [ ] Other [ ]
Remarks:
PERSONAL INFORMATION
(Provide the following information on the individual you want DES to conduct background name check on)
NAME
Last
First
Middle
Rank
SSN
Date of Birth
Place of Birth
REQUESTER INFORMATION
Organization:
Name
Youth Sports & Fitness
Phone # 5804425926
Military Police [ ]
Derogatory Check
Remarks
FS Form 320-E-R
(DES) 14 May 07
[ ]
Signature
Date
****FOR MILITARY USE ONLY****
Lawton Police [ ]
Results of Name Check
Cleared [ ]
Date [ ]
APD PE v1.00
3
AUTHORIZATION FOR DISCLOSURE OF MEDICAL OR DENTAL INFORMATION
PRIVACY ACT STATEMENT
In accordance with the Privacy Act of 1974 (Public Law 93-579), the notice informs you of the purpose of the form and how it
will be used. Please read it carefully.
AUTHORITY: Public Law 104-191; E.O. 9397 (SSAN); DoD 6025. 18-R.
PRINCIPAL PURPOSE(S): This form is to provide the Military Treatment Facility/Dental Treatment Facility/TRICARE Health Plan
with a means to request the use and/or disclosure of an individual’s protected health information.
ROUTINE USE(S): To any third party or the individual upon authorization for the disclosure from the individual for: personal
use; insurance; continued medical care; school; legal; retirement/separation; or other reasons.
DISCLOSURE: Voluntary. Failure to sign the authorization form will result in the non-release of the protected health
information.
This form will not be used for the authorization to disclose alcohol or drug abuse patient information from medical records or
for authorization to use or disclose psychotherapy notes may not be combined with another authorization except one to use
or disclose psychotherapy notes.
SECTION 1 – PATIENT DATA
1. Name (Last, First, Middle Initial)
2. Date of Birth (YYYYMMDD) 3. SSN
4. Period of Treatment: From – To (YYYYMMDD)
5. Type of Treatment (X One)
[ ] Outpatient [ ] Inpatient
SECTION II – DISCLOSURE
[ ] Both
6. I Authorize _______________________________________________ to release my patient information to:
(Name of Facility/TRICARE Health Plan)
a. Name of Physician, Facility, or TRICARE Health Plan
b. Address (Street, City, State and Zip)
c. Telephone (Include Area Code)
d. Fax (Include Area Code)
7. Reason for Request/Use of Medical Information (X as Applicable)
[ ] Personal Use
[ ] Continued Medical Care
[ ] School
[ X ] Other (Specify)
[ ] Insurance
[ ] Retirement/Separation
[ ] Legal
8. Information to be Released
The existence, if any of a Family Advocacy Record where I am identifies as the offender or perpetrator of domestic abuse or
child maltreatment.
9. Authorization Start Date (YYYYMMDD)
10. Authorization Expiration
Date (YYYYMMDD)
Action Completed
SECTION III – RELEASE AUTHORIZATION
I understand that:
a. I have the right to revoke this authorization at any time. My revocation must be in writing and provided to the facility where my medical
records are kept or to the TMA Privacy Officer if this is an authorization for more information possessed by the TRICARE Health Plan
rather than an MTF or DTF. I am aware that if I later revoke this authorization, the person(s) I herein name will have used and/or
disclosed my protected information on the basis of this authorization.
b. If I authorize my protected health information to be disclosed to someone who is not required to comply with federal privacy protection
regulations, then such information may be re-disclosed and would no longer be protected.
c. I have a right to inspect and receive a copy of my own protected health information to be used or disclosed, in accordance with the
requirements of the federal privacy protection regulations found in the Privacy Act and 45 CFR 164.524.
d. The Military Health System (which includes the TRICARE Health Plan) may not condition treatment in MTFs/DTFs, payment by the
TRICARE Health Plan, enrollment in the TRICARE Health Plan or eligibility for TRICARE Health Plan benefits on failure to obtain this
authorization.
I request and authorize the named provider/treatment facility/TRICARE Health Plan to release the information described above to the named
individual/organization indicated.
11. Signature of Patient/Parent/Legal Representative
12. Relationship to Patient
13. Date (YYYYMMDD)
(if applicable)
SECTION IV – FOR STAFF USE ONLY (to be completed only upon receipt of written revocation)
14. X If Applicable:
15. Revocation Completed by
16. Date (YYYYMMDD)
[ ] Authorization Revoked
17. Imprint of Patient Identification Plate When Available
Sponsor Name:
Sponsor Rank:
FMP/Sponsor Rank:
Branch of Service:
Phone Number:
DD FORM 2870, DEC 2003
4
ADAPCP CLIENT’S CONSENT STATEMENT FOR RELEASE OF TREATMENT INFORMATION
For use of this form, see AR 600-85; the proponent agency is DCS, G-1
SECTION A - CONSENT
I, ____________________________________ , this ____________ day of ______________ 20 _____ , do hereby voluntarily
(client’s full name)
consent to the release of the following information by _____________________________________ pertaining to my identity,
(name of installation ADAPCP)
diagnosis, prognosis, or treatment from any Army record maintained in connection with alcohol or other drug abuse
education, training, treatment, rehabilitation, or research to _____________________________________ for the purpose of
_____________________________________________________________________________________________________
_______________________________________________________________________________________________ namely,
_____________________________________________________________________________________________________
(extent or nature of information to be disclosed)
SECTION B – EXPIRATION/REVOCATION
(Check applicable paragraph)
1.
I understand that this consent automatically expires when the above disclosure action has been taken in reliance
thereon and that, except to the extent that such action has been taken, I can revoke this consent at any time.
-OR(For disclosure to civilian criminal justice officials under the provisions of paragraphs 6-9b(4)(b) and 6-10e(3), AR 600-85)
2. I understand that this consent automatically expires 60 days from today’s date or when my present criminal justice
system status changes to ______________________________________________________________
___________________________________________________________________________________
Further, I understand that if my release from confinement, probation, or parole is conditioned upon my
participation in the ADAPCP, I cannot revoke this consent until there has been a formal and effective
termination or revocation of my release from such confinement, probation, or parole.
Signature of Client
Name of Witness (Type or Print)
Date
Signature
Date
SECTION C – APPROVAL AUTHORITY FOR RELEASE OF INFORMATION
Note: Other than the MEDCEN/MEDDAC Commander, approval authority for release of information may be delegated to the
Program Physician or the Clinical Director.
In my judgment, the release of an evaluation of the present or past status of ____________________________________
(client’s name)
in the alcohol or other drug treatment and rehabilitation program will not be harmful to him/her.
Name of MEDCEN/MEDDAC Commander or Designated Representative (Type or Print)
Date
_________________________________
Signature
DA FORM 5018-R, NOV 1981
APD PE v3 00E8
5
IMSI-MWC
Date _________________
MEMORANDUM FOR ARMY SUBSTANCE ABUSE PROGRAM
SUBJECT: Local Installation Background Check for CYSS Volunteer
1.
Request a local installation records check on the following volunteer(s) IAW AR 608-10 and AR 608-18.
Name
2.
SSN
A signed Release Authorization Statement is provided (DA 5018-R). See enclosed.
Encl
IVORY MARSHALL
Coordinator, CYS Services
IMSI-HRS
Date __________________
Army Substance Abuse Program
For: Fort Sill Child, Youth & School Services Program
A local installation records check on the above individual was conducted with the following results:
______________ There is NO DEROGATORY information on file
______________ DEROGATORY information is on file
Remarks:
Signed__________________________________________
6
Appendix D
OFI Form 86C
SPECIAL AGREEMENT CHECKS (SAC)
OFI FORM 86C
MAY 2010
Agency
Agreement
Number
OPM
USE
ONLY
U.S. OFFICE OF PERONNEL MANAGEMENT
INVENTIGATIVE SERVICES
Case Number
OPM Codes
AGENCY USE ONLY (COMPLETE ITEMS 1 THROUGH 14 USING INSTRUCTIONS FROM THE BACK)
1. Subject’s Full Name
Last Name
2. Date of Birth
First Name
Middle Name
Abbrev.
3. Place of Birth – use two letter code for the state
City
County
State
Month
Day
Year
4. Social Security
Country
5. Other Names and Dates When Used
Name
Month/Year to Month/Year
Name
Month/Year
Month/Year to
Name
Month/Year to Month/Year
Name
Month/Year
Month/Year to
6. Sex
[ ] Female [ ] Male
9. SON
10. SOI
7. Special Agreement Codes
8, B
11. IPAC-ALC Number
8. Position Title
12. Accounting Data
13. Other Information Required by Agreement
(CODE 8) Child Care searches – Complete additional information needed for State Criminal History Repository checks. Fill in subject’s
address for every place lived in the past +5 years, beginning with the present and working backwards. If additional space is needed, attach a
continuation sheet to this form.
Month/Year to Month/Year
1.
Month/Year to Month/Year
1.
Street Address
Apt #
City
State
Zip
Street Address
Apt #
City
State
Zip
Street Address
Apt #
City
State
Zip
Street Address
Apt #
City
State
Zip
Street Address
Apt #
City
State
Zip
Street Address
Apt #
City
State
Zip
to
Month/Year to Month/Year
1.
Zip
to
Month/Year to Month/Year
1.
State
to
Month/Year to Month/Year
1.
City
to
Month/Year to Month/Year
1.
Apt #
to
Month/Year to Month/Year
1.
Street Address
to
to
14. Requesting Official Name and Title
Signature
Telephone Number
Date
(including area code)
Phone#
Last Updated: 3 JULY 2013
7
Standard Form 85
Revised December 2013
U.S. Office of Personnel Management
5 CFR Parts 731 and 736
Form Approved
OMB No. 3206-0261
QUESTIONNAIRE FOR NON-SENSITIVE POSITIONS
UNITED STATES OF AMERICA
AUTHORIZATION FOR RELEASE OF INFORMATION
Carefully read this authorization to release information about you, then sign and date it in ink.
I Authorize any investigator, special agent, or other duly accredited representative of the authorized Federal agency
conducting my background investigation or reinvestigation to obtain any information relating to my activities from
individuals, schools, residential management agents, employers, criminal justice agencies, credit bureaus, consumer
reporting agencies, collection agencies, retail business establishments, or other sources of information to include
publically available electronic information. This information may include, but is not limited to, my academic,
residential, achievement, performance, attendance, disciplinary, employment history, and criminal history record
information.
I understand that, for some sources of information, a separate specific release will be needed, and I may be
contacted for such a release at a later date.
I Authorize the Social Security Administration (SSA) to verify my Social Security Number (to match my name, Social
Security Number, and date of birth with information in SSA records and provide the results of the match) to the
United States Office of Personnel Management (OPM) or other Federal agency requesting or conducting my
investigation for the purposes outlined above. I authorize SSA to provide explanatory information to OPM, or to the
other Federal agency requesting or conducting my investigation, in the event of discrepancy.
I Authorize custodians of records and other sources of information pertaining to me to release such information
upon request of the investigator, special agent, or other duly accredited representative of any Federal agency
authorized above regardless of any previous agreement to the contrary.
I Understand that the information released by records custodians and sources of information is for official use by
the Federal Government only for the purposes provided in this Standard Form 85, and that it may be disclosed by
the Government only as authorized by law.
Photocopies of this authorization with my signature are valid. This authorization is valid for two (2) years from the
date signed.
Signature (Sign in Ink)
Full Name (Type or Print Legibly)
Date Signed (MM/DD/YYYY)
Other Names Used
Current Street Address Apt #
Social Security Number
City (Country)
State
Zip Code
Home Telephone Number
8
SUPPLEMENTAL – A EMPLOYMENT APPLICATION FORM FOR CHILD – YOUTH SERVICES POSITIONS
For use of this form, see AR 215-3; the proponent agency is DCS, G1.
DATA REQUIRED BY THE PRIVACY ACT OF 1974
AUTHORITY:
Public Law 101-64
PRINCIPAL PURPOSE: To determine your eligibility for service in a child care services position.
ROUTINE USES:
We must have your social security number (SSN) to keep your records straight because
other people may have the same name and birth date. The SSN has been used to keep
records since 1943, when Executive Order 9397 asked agencies to do so. We may also use
your SSN to make requests for information about you from employers, schools, banks,
and others who know you, but only where allowed by law. The information we collect by
using your SSN will be used for employment purposes, and also for studies and statistics
that will not identify you.
DISCLOSURE:
Your responses to the collection of this information are voluntary, but we cannot
determine your eligibility, which is the first step toward getting the job, if you do not
answer these questions.
1. Name
2a. SSN
4. Address
2b. DOB (YYYY-MM-DD)
5. Work Phone
7. Face Telephone Number
3. Job Announcement/Title
6. Home Phone
8. E-Mail Address
9. HAVE YOU EVER BEEN ARRESTED FOR OR CHARGED WITH A SEX CRIME, A CRIME INVOLVING A CHILD, A SUBSTANCE ABUSE
FELONY OR A VIOLENT CRIME? HAVE YOU EVER BEEN ASKED TO RESIGN BECAUSE OF OR BEEN DECERTIFIED FOR A SEXUAL
OFFENSE?
If so, provide a description of the case disposition.
[
] YES
[
] NO
Note: A false statement rendered by an employee may result in adverse action up to and including removal.
Under 18 U.S. Code 1001, the federal punishment for perjury is fine or imprisonment for up to 5 years, or both.
I declare under penalty of perjury that the information contained in this application form and any attachments or documents
submitted in connection with my application for this position are true and correct to the best of my knowledge, information, and
belief.
10. Signature
11. Date (YYYY-MM-DD)
DA FORM 3433-2. AUG 2002
DA FORM 3433-2, JAN 2002, IS OBSOLETE
USAPA V1 .GOES
9
VOLUNTEER AGREEMENT FOR
[ X ] Nonappropriated Fund Instrumentalities
PART 1 – GENERAL INFORMATION
1. Typed Name of Volunteer (Last, First, Middle Initial)
2. Year of Birth
[ ] Appropriated Fund Activities
3. Installation
4. Organization/Unit Where Service Occurs
5. Program Where Service Occurs
6. Anticipated Days of Week
7. Anticipated Hours
8. Description of Volunteer Services
PART II – VOLUNTEER IN APPROPRIATED FUND ACTIVITIES
9. CERTIFICATION
I expressly agree that my services are being provided as a volunteer and that I will not be an employee of the United States Government or
any instrumentality thereof, except for certain purposes relating to compensation for injuries occurring during the performance of approved
volunteer services, tort claims, the Privacy Act, criminal conflicts of interest, and defense of certain suits arising out of legal malpractice. I
expressly agree that I am neither entitled to nor expect any present or future salary, wages, or other benefits for these voluntary services. I
agree to be bound by the laws and regulations applicable to voluntary service providers and agree to participate in any training required by
the installation or unit in order for me to perform the voluntary services that I am offering. I agree to follow all rules and procedures of the
installation or unit that apply to the voluntary services I will be providing.
A. Signature of Volunteer
B. Date Signed (YYYYMMDD)
10A. Typed Name of Accepting Official
B. Signature
C. Date Signed (YYYYMMDD)
(Last, First, Middle Initial)
PART III – VOLUNTEER IN NONAPPROPRIATED FUND INSTRUMENTALITIES
11. CERTIFICATION
I expressly agree that my services are being provided as a volunteer and that I will not be an employee of the United States Government or
any instrumentality thereof, except for certain purposes relating to compensation for injuries occurring during the performance of approved
volunteer services and liability for tort claims as specified in 10 U.S.C. Section 1588(d)(2). I expressly agree that I am neither entitled to nor
expect any present or future salary, wages, or other benefits for these voluntary services. I agree to be bound by the laws and regulations
applicable to voluntary service providers, and agree to participate in any training required by the installation or unit in order for me to
perform the voluntary services that I am offering. I agree to follow all rules and procedures of the installation or unit that apply to the
voluntary services that I am offering.
A. Signature of Volunteer
12A. Typed Name of Accepting Official
B. Date Signed (YYYYMMDD)
B. Signature
C. Date Signed (YYYYMMDD)
PART IV – TO BE COMPLETED AT END OF VOLUNTEER’S SERVICE BY VOLUNTEER SUPERVISOR
13. Amount of Volunteer Time Donated
14. Signature
15. Termination
Date (YYYYMMDD)
A. Years
B. Weeks
C. Days
D. Hours
(2,087 hours 1 year)
16A. Typed Name of Supervisor
B. Signature
(Last, First, Middle Initial)
DD FORM 2793, MAY 2009
C. Date Signed
Date (YYYYMMDD)
PREVIOUS EDITION IS OBSOLETE.
Adobe Professional 8.0
10
VOLUNTEER SERVICE RECORD
For use of this form, see AR 608-1; the proponent agency is OACSIM
PRIVACY ACT STATEMENT
Authority: 5 USC Section 301, Department Regulations; 10 USC Section 3013, Secretary of the Army; and Army Regulation
608-1, Army Community Service Center.
Principal Purpose: To record essential background information on volunteers to assist in determining qualifications and task
assignments. To maintain record of positions held, hours volunteered, training and awards received.
Routine Uses: None. The “Blanket Routine Uses” set forth at the beginning of the Army’s Complications of System of Records
Notices apply to this system.
Disclosure: Voluntary. However, failure to provide the requested information may exclude you from participating in the Army
Community Service Volunteer Program.
INSTRUCTIONS: Upon resignation, retirement or transfer, the original of this record will be furnished for the personal file of
the volunteer and a duplicate will be maintained at the organization for at least three years. In case of transfer, a duplicate
record will be furnished to the gaining organization upon request of the volunteer.
1. Name of the Volunteer (Last, First, MI)
2. Home Address (Street, City, State and Zip Code)
3. E-Mail Address
4. Telephone Numbers
5. Sex
[ ] Male [ ] Female
6. Date of Birth (YYYYMMDD)
7A. Sponsor Name
7B. Sponsor Unit Address
8. Mark all the demographic data that applies to the volunteer. Family members of service members should indicate the
branch of service and status of the sponsor.
[ ] Service Member
[ ] Army
[ ] Air Force
[ ] Navy
[ ] Marine
[ ] Civilian Employee
[ ] Officer
[ ] Enlisted
[ ] Active Duty
[ ] Adult Family Member
[ ] Reserve
[ ] Guard
[ ] Deceased
[ ] Youth Family Member
[ ] Civilian
[ ] Retired
(APF and NAF)
(Under age 18 and unmarried)
9. Children at Home
[ ] None
[ ] Preschool
11. Education
[ ] High School [ ] College
12. Work Experience
(Not Connected with the military)
10. Initial Commitment
[ ] In School
[ ] One Day Event [ ] One Month Event [ ] Three Months
[ ] Six Months
[ ] Nine Months
[ ] Other
[ ] Advanced Degree
13. Volunteer Experience
DA FORM 4162, JUL 2003
DA FORM 4162, MAY 1998, IS OBSOLETE.
USAPA V1.00
11
14. Special Skills, Interest, Hobbies
15. Positions Held
Start Date
(YYYYMMDD)
Type of Position
End Date
(YYYYMMDD)
16. Awards and Special Recognition
Start Date
(YYYYMMDD)
Type of Position
Presented At
17. Training
Start Date
(YYYYMMDD)
Type of Position
Hours
Completed
18. Volunteer Annual Hour Record
Year
Hours
19A. Signature
DA FORM 4162, JUL 2003
19B. Date (YYYYMMDD)
USAPA V1.00
12
1.
Cigarettes/tobacco products will not be used within at least 50 feet on or near a SF program, facility, or field.
2.
All SF staff, volunteers, coaches, and instructors will wear name tags which promote child, youth, and parent
interaction with staff.
3.
Volunteer coaches may be counted in ratio.
4.
Ages 6-18 years of age ratio is 1:15
5.
CYS Services staff should NOT use privately owned vehicles to transport children and youth.
6.
A primary goal of the SF program is parental involvement. Parents should be looked upon as partners.
7.
A child’s information should be kept confidential. Do not share contact information with people that do not
need to know. Coaches are the only ones that should have a copy of the roster and special needs information.
8.
Accidental Prevention Response:
a. Identify the injury and administer first aid
b. Call for help
c. Notify the parent/legal guardian
d. Notify the supervisor/coordinator
e. Obtain Medical Power of Attorney from participant’s file
f. Stay with the participant
g. Fill out an accident/serious incident report
h. Report injuries requiring more than first aid
9.
All indoor or outdoor activity spaces must be visually and physically accessible to multiple adults for supervision
purposes.
10. The YS and F Director and Assistant Director are in charge: DO NOT COME IN AND TELL US WHAT YOU ARE
DOING! ASK AND DISCUSS WITH US! This is our Job!!
______________________________________
_____________________
Signature
Date
13
SUBJECT: STANDARD OF CONDUCT, CARE, AND PERFORMANCE LETTER
My signature acknowledges that I have read, understand, and will comply with the Standard of Conduct,
Care, and Performance SOP on appropriate guidance & discipline, touching, and accountability of
children/youth in CYS Services programs. I understand that my failure to adhere to the SOP and this
Standard of Conduct, Care, and Performance Letter could lead to disciplinary action including removal or
separation from my position.
______________________________________
_____________________
Employee Signature
Date
14
IMSI-MWC
SUBJECT: STANDARD OPERATING POSITION PROCEDURE (SOP), CHILD ABUSE PREVENTION AND
RESPONSE CAPR, TOUCH AND ACCOUNTABILITY IN CHILD, YOUTH AND SCHOOL (CYS) SERVICES 2013
SIGN BELOW FOR ANNUAL REVIEW (PLACE COPY IN STAFF MEMBER’S FILES)
______________________________
Employee Printed Name
______________________________
Employee Signature
Date
______________________________
Supervisor’s Printed Name
______________________________
Supervisor’s Signature
Date
______________________________
Program Director’s Printed Name
______________________________
Program Director’s Signature Date
______________________________
Employee Printed Name
______________________________
Employee Signature
Date
______________________________
Supervisor’s Printed Name
______________________________
Supervisor’s Signature
Date
______________________________
Program Director’s Printed Name
______________________________
Program Director’s Signature Date
______________________________
Employee Printed Name
______________________________
Employee Signature
Date
______________________________
Supervisor’s Printed Name
______________________________
Supervisor’s Signature
Date
______________________________
Program Director’s Printed Name
______________________________
Program Director’s Signature Date
15