Coaches Information Request Form


Information Request Form
  CONTACT INFORMATION
Name
Home Address
Home City
Home State
Home Zip
Day Phone
Evening Phone
Cell Phone
Where shall we send your paychecks? If same as above, click here
Address for Check
City for Check
State for Check
Zip for Check
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.
E-Mail
Date of Birth
Driver’s License Number
Social Security Number (i.e. 123-45-6789)
Emergency Contact Name
Emergency Contact Phone
  INSURANCE INFORMATION
Health Insurance Company
Health Insurance ID #
Auto Insurance Company
Auto Insurance Policy #
Other Insurance Company (not Mandatory)
Other Insurance Policy #
  COACHING INFORMATION
Your Staff Director Last Name
Your Current Employer or School
Weeks Available To Work
June 10-14
June 17-21
June 24-28
July 8-12
July 15-19
July 22-26
  REFERENCES
Tell Us Your Relevant Experience for Coaching
Provide a minimum of THREE references with telephone number, email Address and relationship to you
Reference #1 Name
Reference #1 Relationship to You
Reference #1 Telephone Number
Reference #1 Email Address
Reference #2 Name
Reference #2 Relationship to You
Reference #2 Telephone Number
Reference #2 Email Address
Reference #3 Name
Reference #3 Relationship to You
Reference #3 Telephone Number
Reference #3 Email Address
Reference #4 Name
Reference #4 Relationship to You
Reference #4 Telephone Number
Reference #4 Email Address
  MEDICAL
Do You Have Any Med Issues We Should Be Aware of?
List Any Allergies or Medical Conditions You Have
  CRIMINAL
Have you ever been convicted of a felony?
If yes, please provide the details.
Yes, I authorize Pro Sports Experience to conduct a background check on me.
CHECK indicates YES
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