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2. League/Team Name*
3. Season of Play*
5. Coach/Volunteer Roster*

   Please attach a current roster of all coaches and volunteers who have successfully completed/passed a background check for this season.  

7. League Liability Statement for Coaches Working with Minors

   By participating in league activities, the league stated above, hereby confirms that all coaches working with minors have successfully completed the required background check process. This process includes a comprehensive review, that meets Powhatan Parks and Recreations Department’s minimum guidelines to ensure the safety and well-being of all participants. All coaches are certified as having passed the necessary criminal background checks and have been deemed fit to engage in league activities involving minors. 

   In the event of any concern regarding a coach's eligibility, the league and Parks and Recreation Department reserve the right to re-evaluate participation at any time. By engaging in these activities, the league affirms its commitment to maintaining a safe and secure environment for all minor participants. 

9. League Representative Name*
10. Title*
12. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
14. Electronic Signature*
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16. 1. Receive an email copy of this form.
17. Email address

    This field is not part of the form submission.

18. Submit

* indicates a required field