Information Request Form
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| CONTACT INFORMATION |
| Name |
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| Home Address |
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| Home City |
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| Home State |
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| Home Zip |
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| Day Phone |
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| Evening Phone |
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| Cell Phone |
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| Where shall we send your paychecks? If same as above, click here |
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| Address for Check |
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| City for Check |
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| State for Check |
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| Zip for Check |
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Be sure your "Pay Check Mailing Address" is accurate! In the unfortunate event you submit an inaccurate address, your paycheck willl be reduced by $40 for a lost/stolen check re-issue.
Please allow up to two weeks to receive payment following the last camp day.
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| E-Mail |
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| Date of Birth |
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| Driver's License Number |
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| Social Security Number |
(i.e. 123-45-6789) |
| Emergency Contact Name |
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| Emergency Contact Phone |
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| INSURANCE INFORMATION |
| Health Insurance Company |
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| Health Insurance ID # |
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| Auto Insurance Company |
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| Auto Insurance Policy # |
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| Other Insurance Company (not Mandatory) |
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| Other Insurance Policy # |
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| COACHING INFORMATION |
| Your Staff Director Last Name |
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| Your Current Employer or School |
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Weeks Available To Work |
| June 14-18 |
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| June 21-25 |
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| June 28-July 2 |
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| July 5-9 |
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| July 12-16 |
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| July 19-23 |
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| July 26-30 |
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| REFERENCES |
| Tell Us Your Relevant Experience for Coaching |
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Provide a minimum of THREE references with telephone number, email Address and relationship to you |
| Reference #1 Name |
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| Reference #1 Relationship to You |
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| Reference #1 Telephone Number |
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| Reference #1 Email Address |
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| Reference #2 Name |
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| Reference #2 Relationship to You |
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| Reference #2 Telephone Number |
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| Reference #2 Email Address |
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| Reference #3 Name |
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| Reference #3 Relationship to You |
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| Reference #3 Telephone Number |
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| Reference #3 Email Address |
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| Reference #4 Name |
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| Reference #4 Relationship to You |
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| Reference #4 Telephone Number |
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| Reference #4 Email Address |
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| MEDICAL |
| Do You Have Any Med Issues We Should Be Aware of? |
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| List Any Allergies or Medical Conditions You Have |
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| CRIMINAL |
| Have you ever been convicted of a felony? |
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| If yes, please provide the details. |
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Yes, I authorize Pro Sports Experience to conduct a background check on me.
CHECK indicates YES
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I acknowledge that in the cases of lost, stolen checks or reissued payment checks, I am subject to a $40 reissued check fee.
CHECK indicates YES |
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2011