Summer Recreation Background Form

Thank you for your interest in becoming a Summer Recreation Volunteer!

Please complete the following background check form. If you have any questions, please contact City Hall at 723-3702.

Name *

Address *

Phone Number

Date of Birth

Licensed in Wisconsin? Yes
No

If no, please list other states where you have been licensed

Volunteer Position * Referee
Umpire
Coach

Please list the program you are interested in coaching

Have you worked with children in the past, if so what kind of work did it consist of?

I HEREBY CERTIFY THAT I HAVE PERSONALLY COMPLETED EACH PAGE OF THIS STATEMENT AND THAT ALL STATEMENTS ARE TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE AND BELIEF. I UNDERSTAND THAT ANY MISSTATEMENT OF MATERIAL FACT MAY SUBJECT ME TO DISQUALIFICATION; OR, IF I HAVE BEEN APPOINTED, MAY DISQUALIFY ME FROM CONTINUED EMPLOYMENT.

Please certify that you have completed statements to the best of your knowledge. * Yes

* - denotes required field