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Last Name: *
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First Name: *
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Middle Initial: *
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Title: *
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Other Name(s) under which transcripts, certificates, and former applications may be listed.:
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Date of Birth: *
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Current Employer: *
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Do You Have a Valid Driver's License?:*
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Community Affiliations (Clubs, Service Organizations, etc.):
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| Contact Information |
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Street Address: *
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Apt. Number:
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City: *
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State: *
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Zip Code: *
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Primary Phone: *
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Home Phone:
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Cell Phone:
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Work Phone:
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Email Address: *
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| Position Desired |
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Position Desired: *
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Experience in Similar Positions: *
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Do You Have a Child in the Program? If Yes, What Activity & Grade Level?:*
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| Experience |
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Do You Have an ASEP Certification?:*
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Special Professional Training & Skills:
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Previous Volunteer Experience (Including Other Youth Sports and Year): *
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| Education |
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High School Attended: *
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Graduation Status: *
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Colleges, Universities, and Technical Schools Attended:
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Graduation Status:
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| Extracurricular Activities |
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Are You a Member of the Dixon Jr. Tackle/Dixon Junior Dukes Alumni?:*
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High School Athletics (Include Sport, School, & Year):
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College Athletics (Include Sport, School, & Year):
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| Professional References |
| Reference 1 |
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Name: *
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School/Organization: *
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Current Position: *
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Phone: *
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Mailing Address: *
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Email: *
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Relationship to Candidate: *
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Years Known: *
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| Reference 2 |
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Name: *
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School/Organization: *
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Current Position: *
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Phone: *
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Mailing Address: *
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Email: *
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Relationship to Candidate: *
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Years Known: *
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| Reference 3 |
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Name: *
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School/Organization: *
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Current Position: *
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Phone: *
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Mailing Address: *
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Email: *
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Relationship to Candidate: *
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Years Known: *
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| Additional Information |
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List any additional information which will help in determining your qualifications for a position:*
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| Disclosures |
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Have you ever had a coaching certificate revoked or suspended? If Yes, explain:*
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Have you ever failed to be rehired, been asked to resign a position, resigned to avoid termination, or terminated from a coaching position? If Yes, explain:*
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Is there anything from your past that could cause Dixon Junior Dukes problems with respect to public relations? If Yes, explain:*
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Can you perform all the essential job functions of the position for which you are applying, with or without reasonable accommadation?:*
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| List any accommodations: |
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| Coaching Questions |
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What athletic experiences have you had that enhance your capabilities as a coach?: *
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Outline briefly your philosophy as it applies to winning: *
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Outline briefly your philosophy as it applies to sportsmanship: *
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Outline briefly your philosophy as it applies to discipline: *
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Explain those factors that you feel are most important to a quality athletic youth program: *
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| Legal Information |
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Please note: Applicants are not obligated to disclose sealed or expunged records of conviction or arrest.
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Have you ever been convicted of a criminal offense other than a minor traffic violation? If Yes, explain, giving dates:*
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Have you ever had any indicated finding of child abuse filed in your name? If Yes, explain, giving dates:*
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Does your name appear on any Sex Offender Database in any state or country?:*
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| Confirmation |
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By checking the appropriate boxes, the candidate confirms that they have fully read and agree to abide by the respective documents content.
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Coaching Contract
Parent & Participant Handbook
I5 Conference By-Laws
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| Coaching Shirt Size: |
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By submitting this application, I give permission for the Dixon Junior Dukes, and/or its chartered member Associations to conduct an investigative background check on me, which may include review of sex offender registries, child abuse and criminal history records, past organizations, all references and any other person to answer all questions asked concerning my ability, character, reputation, and previous volunteer record. I understand that, if appointed, my position is conditional upon the Board of Directors receiving no inappropriate information on my background.
I hereby release and agree to hold harmless from liability the Dixon Junior Dukes, Incorporated, their chartered member Associations, the officers, employees and volunteers thereof, or any other person or organization that may provide such information. I also understand that, regardless of previous appointments, the Dixon Junior Dukes, and its chartered member Associations, are not obligated to appoint me to a volunteer position at this time.
If appointed, I understand that, prior to the expiration of my term, I am subject to suspension by the Dixon Junior Dukes President and removal by the Board of Directors for violation of policies or principles.
The Dixon Junior Dukes, and its chartered member Associations will enforce a "zero tolerance" policy against any adult volunteer that violates the code of conduct, policies and principles.
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