BACKGROUND CHECK FORM
Non-Profit Organization
2018 Season AUTHORIZATION & RELEASE FORM Dear Potential Manager and/or Coach: By Miami-Dade County Ordinance Section 26-38A all Managers and Coaches will be required to submit to a background check prior to being allowed to manage or coach a youth league team. In order to comply with these requirements, we ask that you complete the information below along with your signature authorizing Tamiami Youth Baseball Association (TYBA) to conduct this required background check. Please be informed that the results of the background check will be available to the public, through the county, including the media, at some future time. In addition, the names and address of all coaches in TYBA are submitted to Miami-Dade Park and Recreation (MDPR) becoming public records. Please note, as per public record law the list is subject to disclosure to any party that requests it from the county, however, there are exemptions to the public record law that allow for your home address to not be included in any request. Please see the back of this form for the list of exemptions and mark the applicable one along with your signature. By my signature I authorize TYBA to conduct any and all necessary background checks, authorize the release of information to TYBA & release TYBA from all liability in obtaining and releasing the enclosed information. I further certify that all information is true and correct to the best of my knowledge.
FULL NAME: ADDRESS: (Street Address)
DATE OF BIRTH: PLAYER’S NAME:
SS #
(City)
(State)
PHONE #:
DIVISION & TEAM NAME:
EXEMPT FROM PUBLIC RECORD ? YES/NO IF YES, EXEMPTION # IS:
SIGNATURE:
(Zip Code)
BACKGROUND CHECK FORM
PUBLIC RECORDS EXCEPTIONS REQUEST
(please check one if applicable)
1) Active or former law enforcement personnel, which is defined as, a law enforcement officer, a correctional officer, a correctional probation officer, a part-time law enforcement officer, a part-time correctional officer, an auxiliary law enforcement officer, an auxiliary correctional officer, any county probation officer; employee or agent of the Department of Corrections who supervises or provides services to inmates; officer of the Parole Commission; and law enforcement personnel of the Fish and Wildlife Conservation Commission, the Department of Environmental Protection, or the Department of Law Enforcement. personnel of the Department of Children and Family Services whose duties include the investigation of abuse, neglect, exploitation, fraud, theft, or other criminal activities, personnel of the Department of Health whose duties are to support the investigation of child abuse or neglect, and personnel of the Department of Revenue or local governments whose responsibilities include revenue collection and enforcement or child support enforcement (spouses and children included) 2) Firefighters (spouses and children included) 3) Justices of the Supreme Court, district court of appeal judges, circuit court judges, and county court judges (spouses and children included) 4) Current or former state attorneys, assistant state attorneys, statewide prosecutors, or assistant statewide prosecutors (spouses and children included) 5) Current or former human resource, labor relations, or employee relations directors, assistant directors, managers, or assistant managers of any local government agency or water management district whose duties include hiring and firing employees, labor contract negotiation, administration, or other personnelrelated duties (spouses and children included) 6) Current or former United States attorneys and assistant United States attorneys (spouses and children included) 7) Current or former judges of United States Courts of Appeal, United States district judges, and United States magistrate judges (spouses and children included) 8) Current or former code enforcement officers (spouses and children included) 9) Current or former guardians ad litem (spouses and children included) 10) Current or former juvenile probation officers, juvenile probation supervisors, detention superintendents, assistant detention superintendents, senior juvenile detention officers, juvenile detention officer supervisors, juvenile detention officers, house parents I and II, house parent supervisors, group treatment leaders, group treatment leader supervisors, rehabilitation therapists, and social services counselors of the Department of Juvenile Justice (spouses and children included)
Signature: _____
Date:_______________________
Name: _____
Player’s Name:_______________________
Team Name: _____
Team Date:_______________________
