YOUTH SPORTS APPLICATION FOR VOLUNTEERS PRIVACY ACT STATMENT

AUTHORITY, the information contained on this form is maintained under the systems of records notice NM01700-1 General Morale, Welfare, and Recreation Records 10 U.S.C. 1071-1087 and E.O. 116016, published February 12, 2008, 73 FR 8036. The information contained within is FOR OFFICIAL USE ONLY and may not be disclosed without the consent of the record's subject, except under routine use. PURPOSE of this information is to document the approval and conduct of sports activities and to enable fitness/sports facility personnel to determine the appropriate level of activity participation. In addition to those disclosures generally permitted under 5 U.S.C. 552a (b) of the Privacy Act, these records or information contained therein may specifically be disclosed outside the DoD ROUTINE USE pursuant to 5 U.S.C. 552a (b). DISCLOSURE MANDATORY

Background Check Date New Coach Yes No Returning Coach Yes No

Sport Division

Team

Do you have a child/children on the team? YES NO

Child(ren)'s Name(s)

VOLUNTEER'S INFORMATION

Name Grade Last 4 digits of SSN

Home Address

Military Address

Home Phone Office Phone

Military Sponsor

Position for which you are applying:

Head Coach - Must be 18 or over

Assistant Coach - Must be 16 or over

Team Mom/Dad

Email address

Three references to whom you are not related:

1. Phone

2. Phone

3. Phone

NOAre you NYSCA (National Youth Sports Coaches Association) certified? YES

Expiration Date:

What year were you last certified?

Please give certification number:

Please list last three coaching jobs:

1.

2.

3.

Age group you would like to coach (please list three choices - if applicable):

1.

2.

3.

MCBCL/MCCS/SPORT/6 (8/17) PREVIOUS EDITIONS ARE OBSOLETE ADOBE 9.0

OFFICIAL USE ONLY

Note: Request for background check must be completed, submitted and endorsed by MCCS prior to any authorized coaching or volunteering with Youth Sports.

Date of Birth Age

NOAre you CPR and First Aid certified? YES

Expiration Date:What organization are you certified through?

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Volunteer Administrator (Game Day)

OTHER PERSONAL INFORMATION: CRIMINAL RECORD

A conviction does not necessarily mean that you cannot be employed as a volunteer. The circumstance of the occurrence(s) and when it/they occurred are important. You may omit (1) traffic offences, (2) any offences that you committed before your 18th birthday that were processed in a juvenile court under a youthful offender law, and (3) convictions set aside under the Federal Youth Corrections Act or similar authority.

NO During the past seven years have you been convicted, imprisoned, on probation, on parole or are you now under charges for any offense against the law? This includes simple assault and shoplifting. ANSWER YES

Have you ever been convicted, or are you under any charges for a felony? (A felony is defined as any offense identified as a felony, punishable by imprisonment for a term exceeding one year) ANSWER YES NO

While in military service, were you ever convicted by General Court-Martial? ANSWER YES NO NOT APPLICABLE

Have you ever been asked to resign because of or been decertified for a sexual offense? ANSWER YES NO

(Applicant's Signature) Date

MCBCL/MCCS/SPORT/6 (8/17) PREVIOUS EDITIONS ARE OBSOLETE ADOBE 9.0

2

Have you ever been arrested for or charged with a crime involving a child? ANSWER YES NO

If you answered "YES" to any of the above questions, please give details below. Be sure to include (1) Date of Offense, (2) Charge, (3) Place, (4) Type of Court, (5) Action Taken, (6) Length of Probation.

UNITED STATES MARINE CORPS MARINE CORPS COMMUNITY SERVICES, LEJEUNE-NEW RIVER

MARINE CORPS INSTALLATIONS EAST 1401 WEST ROAD

CAMP LEJEUNE NC 28547

BACKGROUND CHECK AUTHORIZATION

VOLUNTEER FOR RECREATIONAL & ATHLETIC PROGRAMS

Per DoD Instruction 1402.05, individuals who have regular contact with children under 18 years of age in DoD Child and Youth or other sanctioned child care services programs, including health and mental care, recreational and athletic programs will undergo a criminal history background check in order to protect the health, safety, and well-being of children in such programs. Individuals who have a current or prior DoD affiliation must also undergo installation record checks (IRC).

I am aware of the provision of the Privacy Act of 1974 (5 U.S.C. 552a) and of the personal nature of the information involved. I hereby authorize the release of information needed directly to the requested and to such other officers and persons having a need to know in the discharge of their official duties.

I further authorize any individual, company, firm, corporation, or public agency to divulge any and all information, verbal or written, pertaining to me, to MCCS or its agents. I further authorize the complete release of any records or data pertaining to me which the individual, company, firm, corporation, or public agency may have, to include information or data received from other sources.

I further understand that my employment as a volunteer is conditional pending a records check and that a false statement may be grounds for removal from contract.

Please Print Name ____________________________________________________

Volunteer Signature ___________________________________________________

Date: _____________________________

MCBCL/MCCS/SPORT/6 (8/17) PREVIOUS EDITIONS ARE OBSOLETE

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AUTHORITY: Title 10 U.S. Code §§ 5014 and 5020 PURPOSE: To identify authorized individuals who will be obligating federal funds for payroll disbursement. Disclosure of Social Security Account Number and date of birth is mandatory and is used to further identify the individual providing the information. ROUTINE USES: The information is entered into the Marine Corps Community Services Human Resources Management System (HRMS), PeopleSoft, and authorizes the individual to obligate Federal Funds for Family Readiness Officer Payroll. MANDATORY OR VOLUNTARY DISCLOSURE AND EFFECT ON INDIVIDUAL NOT PROVIDING INFORMATION: Disclosure of personal information is mandatory for all individuals entered into the HRMS. No action can be taken against individuals for refusing to provide information about them however access to the HRMS PeopleSoft will be denied. ACKNOWLEDGMENT: I understand the provisions of the Privacy Act of 1974 as related to me through the foregoing statement.

Contingent Worker PeopleSoft Input REQUEST FORM

PLEASE ENSURE ALL FIELDS ARE COMPLETED AND ACCURATE. The information on this form is required in order to enroll you into MCCS PeopleSoft Human Resources Management System. Your complete SSN and Date of Birth are required.

Biographical DetailsToday's Date

First Name:

Middle Name:

Last Name:

Rank:

Birth Date: This information is required

Full SSN: This information is required

Contact Information

City:

Postal Code:

State:

Email:

Mailing Address:

Phone Number:

Work Location

Work Location:

Department: (cost center #)

Position Title:

Volunteer Signature Date

Return this form to Human Resources. You will receive an email with your Employee ID #.

MCBCL/MCCS/SPORT/6 (8/17) PREVIOUS EDITIONS ARE OBSOLETE ADOBE 9.0

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UNITED STATES MARINE CORPS MARINE CORPS COMMUNITY SERVICES LEJEUNE-NEW RIVER

MARINE CORPS INSTALLATIONS EAST 1401 WEST ROAD

CAMP LEJEUNE NC 28547

12330/2 NAFP-3AM

From: Director, Human Resources Division To: Provost Marshal

Subj: REQUEST FOR BACKGROUND CHECK

Ref: (a) MCO P12000.11A w/ Ch 1-5

1. Pursuant to paragraph 2104 of reference (a), a background checkutilizing locally held and locally available records or, if appropriate,records held at a previous command, is requested in the case of

________________________, SSN_______________ whose military sponsor is

________________________, SSN_______________ and who (sponsor) arrived

in the Camp Lejeune area from ____________________________________ on City State/Country

____________________________. Month Year

ANDREW D. ENNETT III

I am aware of the provision of the Privacy Act of 1974 (5 U.S.C. 552a) and of the personal nature of the information involved. I hereby authorize the release of information needed directly to the requested and to such other officers and persons having a need to know in the discharge of their official duties.

________________________________ Applicant Signature

From: Provost Marshal To: Director, Human Resources Division

Subj: REQUEST FOR BACKGROUND CHECK

1. The requested background check completed on _____________ revealedthe following information:

UNITED STATES MARINE CORPS MARINE CORPS COMMUNITY SERVICES LEJEUNE-NEW RIVER

MARINE CORPS INSTALLATIONS EAST 1401 WEST ROAD CAMP LEJEUNE NC 28547

12000 NAFP-3AM

From: Director, Human Resources Division To: Manager, Behavioral Health Programs

Subj: REQUEST FOR RECORDS CHECK

Ref: (a) DoDI 1402.05

1. In accordance with reference (a), an Installation Record Check(IRC) is required for positions involving child care services. Thisis to request for a record check for the following person:

________________________________, __________________________ (Name) (Social Security Number)

2. Please document the existence of a record. You will be contactedfor additional information if records are found to determinesuitability.

3. Fax your reply to (910) 450-7955 or call (910) 450-5244 to requestfor pick-up.

ANDREW D. ENNETT III

I am aware of the provision of the Privacy Act of 1974 (5 U.S.C. 552a) and of the personal nature of the information involved. I hereby authorize the release of information needed directly to the requested and to such other officers and persons having a need to know in the discharge of their official duties.

_________________________________ Applicant/Employee Signature

From: Manager, Behavioral Health Programs To: Director, Human Resources Division

1. A local records check has been completed. Findings are as follows:

_____ No Records Found

_____ Records Found _____ Adverse (please explain) _____Not Adverse

_________ ________________________________ Date Signature of Reporting Official

UNITED STATES MARINE CORPS MARINE CORPS COMMUNITY SERVICES LEJEUNE-NEW RIVER

MARINE CORPS INSTALLATIONS EAST 1401 WEST ROAD

CAMP LEJEUNE NC 28547

5510 NAFP-3AM

From: Director, Human Resources Division To: Admission Assistant, Substance Abuse Rehabilitation Program Subj: REQUEST FOR RECORDS CHECK Ref: (a) DoDI 1402.05 1. In accordance with reference (a), an Installation Record Check (IRC) is required for positions involving child care services. This is to request for a record check for the following applicant/employee: ________________________________, __________________________ (Applicant/Employee Name) (Social Security Number) 2. Please fax any information obtained as a result of the record check to (910) 450-7955. The bottom of this form may be utilized for that purpose. If adverse information record is found, please provide an explanation.

ANDREW D. ENNETT III I am aware of the provision of the Privacy Act of 1974 (5 U.S.C. 552a) and of the personal nature of the information involved. I hereby authorize the release of information needed directly to the requested and to such other officers and persons having a need to know in the discharge of their official duties. _________________________________ Applicant/Employee Signature From: Admission Assistant, Substance Abuse Rehabilitation Program To: Director, Human Resources Division

SARP DATABASE ADMITS DATABASE

□ A record is found (please explain)

□ A record is found (please explain)

□ No adverse information record found

□ No adverse information record found

□ Adverse information record found (please explain)

□ Adverse information record found (please explain)

COMMENTS:

COMMENTS:

____________ ________________________________ Date Signature of Reporting Official